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BACKGROUND: Though long-term weight loss maintenance is the treatment goal for obesity, weight regain is typical and few studies have evaluated lifestyle habits associated with weight regain. OBJECTIVE: To identify dietary and physical activity habits associated with 6- and 24-month weight regain among participants in a weight loss maintenance clinical trial. DESIGN: Secondary analysis of randomized clinical trial data. PARTICIPANTS: Adult primary care patients with recent, intentional weight loss of at least 5%. MAIN MEASURES: Lifestyle habits included consumption of low-fat foods, fish, desserts, sugary beverages, fruits, and vegetables and eating at restaurants from the Connor Diet Habit Survey; moderate-vigorous physical activity by self-report; steps recorded by a pedometer; and sedentary behavior by self-report. The outcome variable was weight change at 6 and 24 months. Linear regression models estimated adjusted associations between changes in weight and changes in dietary and physical activity habits. KEY RESULTS: Overall, participants (mean (SD): 53.4 (12.2) years old; 26% male; 88% white) maintained weight loss at 6 months (n = 178, mean (SD): − 0.02 (5.70)% change) but began to regain weight by 24 months (n = 157, mean (SD): 4.22 (9.15)% increase). When considered all together, more eating at restaurants, reduced fish consumption, and less physical activity were most consistently associated with weight regain in fully adjusted models at both 6 and 24 months of follow-up. In addition, more sedentary behavior was associated with weight regain at 6 months while reduced consumption of low-fat foods, and more desserts and sugary beverages were associated with weight regain at 24 months. CONCLUSIONS: Consuming less fish, fewer steps per day, and more frequent restaurant eating were most consistently associated with weight regain in primary care patients. Primary care providers may consider addressing specific lifestyle behaviors when counseling patients after successful weight loss. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01946191 ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-06056-x) contains supplementary material, which is available to authorized users.

Objective: The aim of this study is to explore whether specific ethical questions arise with the use of a shared electronic health record (EHR) system, based on the daily experience of primary care physicians (PCPs). Methods: In this qualitative research project, we conducted 14 in-depth semistructured interviews with PCPs in a tertiary hospital setting. Results: We identified 4 themes: 1) PCPs describe the EHR as a medicine with side effects, for which they provide suggestions for improvements; 2) A shared record raises ethical questions related to autonomy and trust; 3) Although use of the EHR often disturbs rapport with the patient, it can also support the patient-doctor interaction when it becomes an active part of the conversation; 4) A shared EHR may cause health care providers (and their relatives) to avoid seeking help for sensitive issues. Discussion: PCPs fear access to results could cause confusion and anxiety in patients, resulting in tensions between autonomy and beneficence. Improved efficiency and quality of care with a shared EHR relies on doctors trusting each other9s input to avoid duplicate tests. However, this might compromise a fundamental skeptical attitude in practicing medicine, and we should be aware of a risk of increased confirmation and anchoring bias. Conclusion: The EHR is considered to be a work in progress—EHR design could be improved by examining physicians9 coping strategies and implementing their suggestions for improvement. Ethical questions related to autonomy, trust, and the status of records that belong to doctor–patients need to be considered in future research and EHR development.

Use of electronic health records (EHR) within clinical encounters is increasingly pervasive. The digital record allows for data storage and sharing to facilitate patient care, billing, research, patient communication and quality-of-care improvement-all at once. However, this multifunctionality is also one of the main reasons care providers struggle with the EHR. These problems have often been described but are rarely approached from a philosophical point of view. We argue that a postphenomenological case study of the EHR could lead to more in-depth insights. We will focus on two concepts-transparency and multistability-and translate them to the specific situation of the EHR. Transparency is closely related to an embodiment relation in which the user becomes less aware of the technology: it fades into the background, becoming a means of experience. A second key concept is that of multistability, referring to how a technology can serve multiple purposes or can have different meanings in different contexts. The EHR in this sense is multistable by design. Future EHR design could incorporate multistable information differently, allowing the provider to focus on patient care when interacting with the EHR. Moreover we argue that the use of the EHR in the daily workflow should become more transparent, while awareness of the computer in the specific context of the patient-provider relationship should increase.

ObjectiveTo improve pneumococcal vaccination (PV) rates among rheumatology clinic patients on immunosuppressive therapy in the outpatient settings.MethodsThis quality improvement project was based on the pre–post intervention design. Phase I of the project targeted patients with rheumatoid arthritis from 13 rheumatology clinics (January 2013–July 2015) on immunosuppressive therapy to receive the pneumococcal polysaccharide vaccine (PPSV23). In the Phase II study (January 2016–October 2017), all patients on immunosuppressive medications regardless of diagnosis were targeted to receive PPSV23 and the pneumococcal conjugate vaccine (PCV13). The best practice alerts (BPAs) for both PVs were developed based on the Centers for Disease Control and Prevention guidelines, which appeared on electronic medical records for eligible patients at the time of assessment by the medical assistant. The BPA was designed to inform the vaccination status and enable the physician to order the PV, or to document refusal or deferral reasons. Education regarding vaccine guidelines, BPAs, vaccination process, and regular feedback of results were important project interventions. The vaccination rates during pre–post intervention for each study phase were compared using chi-square test.ResultsDuring phase I, PPSV23 vaccination rates improved from a 28% preintervention rate to 61.5% (P < 0.0001). During phase II, 77.4% of patients had received either PPSV23, PCV13, or both, compared to 49.6% of patients in the preintervention period (P < 0.0001). The documentation rates (vaccine received, ordered, patient refusal and deferral reasons) increased significantly in both phases.ConclusionElectronic identification of vaccine eligibility and implementation of BPAs with capabilities to order and document resulted in significantly improved PV rates. The process has potential for self-sustainability and generalizability.

BACKGROUND Most adults are not achieving recommended levels of physical activity (150 minutes/week, moderate-to-vigorous intensity). Inadequate activity levels are associated with numerous poor health outcomes, and clinical recommendations endorse physical activity in the front-line treatment of obesity, diabetes, dyslipidemia, and hypertension. A framework for physical activity prescription and referral has been developed, but has not been widely implemented. This may be due, in part, to the lack of feasible and effective physical activity intervention programs designed to coordinate with clinical care delivery. OBJECTIVE This manuscript describes the protocol for a pilot randomized controlled trial (RCT) that tests the efficacy of a 13-week online intervention for increasing physical activity in adult primary care patients (aged 21-70 years) reporting inadequate activity levels. The feasibility of implementing specific components of a physical activity clinical referral program, including screening for low activity levels and reporting patient program success to referring physicians, will also be examined. Analyses will include participant perspectives on maintaining physical activity. METHODS This pilot study includes a 3-month wait-listed control RCT (1:1 ratio within age strata 21-54 and 55-70 years). After the RCT primary end point at 3 months, wait-listed participants are offered the full intervention and all participants are followed to 6 months after starting the intervention program. Primary RCT outcomes include differences across randomized groups in average step count, moderate-to-vigorous physical activity, and sedentary behavior (minutes/day) derived from accelerometers. Maintenance of physical activity changes will be examined for all participants at 6 months after the intervention start. RESULTS Recruitment took place between October 2018 and May 2019 (79 participants were randomized). Data collection was completed in February 2020. Primary data analyses are ongoing. CONCLUSIONS The results of this study will inform the development of a clinical referral program for physical activity improvement that combines an online intervention with clinical screening for low activity levels, support for postintervention behavior maintenance, and feedback to the referring physician. CLINICALTRIAL ClinicalTrials.gov NCT03695016; https://clinicaltrials.gov/ct2/show/NCT03695016. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/18891

Background Resident continuity-clinic (RCC) is a crucial component of ambulatory training in primary care.The no-show rate (NSR) in a large academic center with 60 residents averaged 27% in academic year (AY) 2018, despite an automated phone/text reminder system 3 days prior to appointment, resulting in fragmented care, reduced access and decreased learning opportunities for residents. Objectives To determine whether telephone outreach targeting patients predicted to be at high-risk to no-show can reduce NSR for RCC appointments. Methods A validated machine-learning prediction model developed by data scientists at UPMC for Primary care, generated a daily list of high-risk patients (i.e. =20% risk to no-show). Starting Oct 2018, these patients received a phone-call reminder from a clinical staff, 48 hours prior to their scheduled appointment. The outcomes of the call recorded were confirmed, cancelled, rescheduled, voicemail, not reached. Monthly NSR was tracked from July 2017 through June 2019 and analyzed using control charts. Results Fifty-nine percent (1206/2046) of targeted patients were reached. Of those 89% confirmed and 10% canceled or rescheduled their appointment. The overall no-show rate for RCC appointments in (AY) 2019 decreased to 23%, p Conclusions To our knowledge this is the first study showing that targeted phone outreach for high-risk patients can decrease NSR for RCC appointments, augmenting resident learning opportunities and revenue.

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

Quality improvement (QI) plays a vital role in practice management, patient care, and reimbursement. The authors implemented a 3-year longitudinal curriculum that combined QI didactics, intervention development, and implementation at university-based, community-based, and Veterans Administration–based practices. Highlights included Plan-Do-Study-Act cycle format, team-based collaboration to brainstorm interventions, interdisciplinary QI council to select and plan interventions, system-wide intervention implementation across entire clinic populations with outcome monitoring, and intervention modifications based on challenges. A pre–post survey assessed residents’ confidence in QI skills and interdisciplinary team participation, while quarterly quality data assessed patient outcomes. All 150 internal medicine residents participated. Confidence in QI and interdisciplinary team participation improved significantly ( P < .001). Patient outcomes improved for 6 of 9 targeted projects and were sustained at 1 year. This curriculum is a systems-based innovation designed to improve patient care and encourage interdisciplinary teamwork and can be adopted by residencies seeking to improve engagement in QI.

Background Most adults are not achieving recommended levels of physical activity (150 minutes/week, moderate-to-vigorous intensity). Inadequate activity levels are associated with numerous poor health outcomes, and clinical recommendations endorse physical activity in the front-line treatment of obesity, diabetes, dyslipidemia, and hypertension. A framework for physical activity prescription and referral has been developed, but has not been widely implemented. This may be due, in part, to the lack of feasible and effective physical activity intervention programs designed to coordinate with clinical care delivery. Objective This manuscript describes the protocol for a pilot randomized controlled trial (RCT) that tests the efficacy of a 13-week online intervention for increasing physical activity in adult primary care patients (aged 21-70 years) reporting inadequate activity levels. The feasibility of implementing specific components of a physical activity clinical referral program, including screening for low activity levels and reporting patient program success to referring physicians, will also be examined. Analyses will include participant perspectives on maintaining physical activity. Methods This pilot study includes a 3-month wait-listed control RCT (1:1 ratio within age strata 21-54 and 55-70 years). After the RCT primary end point at 3 months, wait-listed participants are offered the full intervention and all participants are followed to 6 months after starting the intervention program. Primary RCT outcomes include differences across randomized groups in average step count, moderate-to-vigorous physical activity, and sedentary behavior (minutes/day) derived from accelerometers. Maintenance of physical activity changes will be examined for all participants at 6 months after the intervention start. Results Recruitment took place between October 2018 and May 2019 (79 participants were randomized). Data collection was completed in February 2020. Primary data analyses are ongoing. Conclusions The results of this study will inform the development of a clinical referral program for physical activity improvement that combines an online intervention with clinical screening for low activity levels, support for postintervention behavior maintenance, and feedback to the referring physician. Trial Registration ClinicalTrials.gov NCT03695016; https://clinicaltrials.gov/ct2/show/NCT03695016. International Registered Report Identifier (IRRID) DERR1-10.2196/18891

Personal health records (PHRs) typically employ "passive" communication strategies, such as non-personalized medical text, rather than direct patient engagement in care. Currently there is a call for more active PHRs that directly engage patients in an effort to improve their health by offering elements such as personalized medical information, health coaches, and secure messaging with primary care providers. As part of a randomized clinical trial comparing "passive" with "active" PHRs, we explore patients' experiences with using an "active" PHR known as HealthTrak. The "passive" elements of this PHR included problem lists, medication lists, information about patient allergies and immunizations, medical and surgical histories, lab test results, health reminders, and secure messaging. The active arm included all of these elements and added personalized alerts delivered through the secure messaging platform to patients for services coming due based on various demographic features (including age and sex) and chronic medical conditions. Our participants were part of the larger clinical trial and were eligible if they had been randomized to the active PHR arm, one that included regular personalized alerts. We conducted focus group discussions on the benefits of this active PHR for patients who are at risk for cardiovascular disease. Forty-one patients agreed to participate and were organized into five separate focus group sessions. Three main themes emerged from the qualitatively analyzed focus groups: participants reported that the active PHR promoted better communication with providers; enabled them to more effectively partner with their providers; and helped them become more proactive about tracking their health information. In conclusion, patients reported improved communication, partnership with their providers, and a sense of self-management, thus adding insights for PHR designers hoping to address low adoption rates and other patient barriers to the development and use of the technology.

Background: Online tools are a convenient and effective method of delivering lifestyle interventions to obese adult primary care patients. A referral model allows physicians to efficiently direct their patients to the intervention during a primary care visit. However, little is known of physicians’ perspectives and utilization of the referral model for an online lifestyle modification intervention. Objective: The aim was to evaluate the response of primary care providers (PCPs) to a referral model for implementing a year-long online intervention for weight loss to obese adult patients. Methods: The PCPs at six primary care clinics were asked to refer adult obese patients to a year-long online lifestyle intervention providing self-management support for weight loss. Following the 1-year intervention, all providers at the participating practices were surveyed regarding their views of the program. Respondents completed survey items assessing their attitudes regarding the 1-year intensive weight loss intervention and identifying resources they would find helpful for assisting patients with weight loss. Referring physicians were asked about their level of satisfaction with implementing the counseling services using standard electronic health record referral processes. Attitudes toward obesity counseling among referring and nonreferring providers were compared. Impressions of how smoothly the referral model of obesity treatment integrated with the clinical workflow were also quantified. Results: Of the 67 providers who completed the surveys, nonreferring providers (n=17) were more likely to prefer counseling themselves (P=.04) and to report having sufficient time to do so (P=.03) than referring providers (n=50) were. Nonreferring providers were more likely to report that their patients lacked computer skills (76%, 13/17 vs 34%, 17/50) or had less access to the Internet (65%, 11/17 vs 32%, 16/50). Conclusions: Understanding providers’ views and barriers regarding the integration of online tools will facilitate widespread implementation of an online lifestyle modification intervention.

Introduction: Though weight loss can improve health, weight regain is common. Primary care physicians are uniquely positioned to provide counseling for weight loss maintenance given their longitudinal care of patients, yet evidence of simple lifestyle recommendations for maintaining weight loss in primary care patients is lacking. Our objective was to characterize longitudinal associations between diet habits and weight change among primary care patients with recent, intentional weight loss of at least 5%. Methods: This was a secondary analysis of data from a weight loss maintenance clinical trial in a primary care setting that compared two interventions delivered through the electronic health record: continued coaching vs. tracking only. Dietary habits [fried foods, desserts, fruits and vegetables (F&V), and sugar-sweetened beverages (SSB)] were measured by the Connor Diet Habits Survey. Linear regression models were used to evaluate associations (overall and by randomized group) between changes in dietary habits and weight separately at 6- and 24-month follow-up, adjusted for baseline diet habit, age, gender and clinic location. Results: Participants (n=192) were 74% female, 87% white and had baseline mean (SD) age of 53 (12) years, body mass index of 30.4 (5.9) kg/m 2 , and recent weight loss of 11 (8) percent. Overall, participants had mean (SD) weight loss of 0.18 (5.04) kg at 6 months (n=169) and weight gain of 3.26 (7.60) kg at 24 months (n=140). At 6 months, a 1 serving per week increase in dessert intake was associated with 0.53 kg (p=0.030) greater weight gain. Fried foods, F&V, and SSB were not associated with 6-month weight changes. However, by 24 months, an increase of 1 serving per week was associated with greater weight gain of 0.54 kg (p=0.043) for fried foods, 0.80 kg (p=0.031) for desserts, and 2.01 kg (p=0.002) for SSB. A decrease of 1 F&V serving per day was associated with a 0.82 kg (p=0.008) greater weight gain at 24 months. When stratified by randomized group, associations were stronger in the continued coaching vs. tracking only arm. Conclusions: Increased consumption of desserts was associated with weight regain at 6 and 24 months, while increased fried foods and SSB, and decreased F&V were associated with weight regain at 24 months. These data suggest that simple strategies such as improving or at least maintaining dietary intake of fried foods, desserts, F&V, and SSB could help facilitate long-term weight loss maintenance in primary care patients.

Addressing patient health and care behaviors that underlie much of chronic disease continues to challenge providers, medical practices, health systems, and insurers. Improving health and care as described by the Quadruple Aim requires innovation at the front lines of clinical care: the doctor–patient interaction and office practice. This article describes the use of Lean Six Sigma in a quality improvement (QI) effort to design an effective and scalable method for physicians to prescribe health coaching for healthy behaviors in a primary care medical home within a large integrated delivery and financing system. Building on the national Agency for Healthcare Research and Quality and Robert Wood Johnson Foundation–funded Prescription for Health multisite demonstration, this QI case study provides important lessons for transforming patient–physician–practice support systems to better address lifestyle and care management challenges critical to producing better outcomes.

Lifestyle habits of primary care patients with recent, intentional weight loss are unclear and need to be better understood to aid in translational health promotion efforts. We aimed to characterize diet and exercise habits in primary care patients with recent, intentional weight loss, comparing those with greater (≥10%) vs. lesser (5 to10%) weight loss.This was a cross-sectional analysis of baseline data from a randomized trial comparing weight loss maintenance interventions. The study included primary care patients, 18-75 years old, with ≥5% intentional weight loss via lifestyle change in the past 2 years. Participants (74% female, 87% white) had mean age 53 (12) years, body mass index 30.4 (5.9) kg/mOn average, participants reported high fruits and vegetables intake (5 servings/day), and low intake of fried foods (1 serving/week), desserts (1 serving/week) and sugar-sweetened beverages (0 servings/week). Those with greater vs. lesser weight loss had higher intake of fruits and vegetables (p=0.037) and low fat foods or recipes (p=0.019). Average self-reported moderate-vigorous physical activity was 319 (281) minutes/week, with significant differences between greater (374 (328) minutes/week) vs. lesser (276 (230) minutes/week) weight loss groups (p=0.017). By pedometer, 30% had ≥7,500 steps/day; the proportion was higher in greater (43%) vs. lesser (19%) weight loss groups (p=0.005).For weight loss, clinical patients typically employ simple strategies such as 5+ fruits and vegetables per day, fried foods and desserts ≤1 per week, elimination of sugary drinks, choosing low fat foods/recipes, and physical activity 45-60 min/day.

Background: Over 140 million people in the United States have at least one chronic medical condition, but they receive fewer than 60% of guideline-recommended services for these conditions. Increasing patients' involvement in their own care may improve the receipt of guideline-recommended services. We evaluated patients' patterns of responses to notifications regarding guideline-recommended services delivered through a personalized health record (PHR). Materials and Methods: We enrolled 584 participants with high cardiovascular disease risk from 73 primary care practices into an active PHR in which they received patient-centered decision support—notifications delivered via a PHR regarding prevention gaps (i.e., unmet preventive healthcare or chronic disease monitoring). Participants with prevention gaps received up to three weekly messages regarding all services due within a 2-month time frame. These three-message cycles could repeat up to every 2 months for a new, or continuing, prevention gap. Results: Of the 584 participants, 501 (86%) received at least one reminder. Approximately 61% of these participants accessed the PHR or received the care that triggered the message after the first message and 73% after the first two messages. In subsequent three-message cycles, we observed no change in the number of messages required prior to participants accessing the PHR or receiving recommended care (chi-squared=12.4, p=0.3). Of the 2,656 prevention gaps these participants had over 1 year, 1,539 (58%) were closed. Conclusions: In this low-intensity intervention, participants accessed the PHR and received recommended care. Providing notification through the PHR allows patients to choose when they receive, and take action on, the message. Notifications can be provided to patients through a PHR without alert fatigue and may be an additional tool to help patients achieve better health.

Background: As electronic health records have become a more integral part of a physician’s daily life, new electronic health record tools will continue to be rolled out to trainees. Patient access to provider notes is becoming a more widespread practice because this has been shown to increase patient empowerment. Objective: In this analysis, we compared differences between resident and attending physicians’ perceptions prior to implementation of patient access to provider notes to facilitate optimal use of electronic health record features and as a potential for patient empowerment. Methods: This was a single-site study within an academic internal medicine program. Prior to implementation of patient access to provider notes, we surveyed resident and attending physicians to assess differences in perceptions of this new electronic health record tool using an open access survey provided by OpenNotes. Results: We surveyed 37% (20/54 total) of resident physicians and obtained a 100% response rate and 72% (31/44 total) of attending physicians. Similarities between the groups included concerns about documenting sensitive topics and anticipation of improved patient engagement. Compared with attending physicians, resident physicians were more concerned about litigation, discussing weight, offending patients, and communicated less overall with patients through electronic health record. Conclusions: Patient access to provider notes has the potential to empower patients but concerns of the resident physicians need to be validated and addressed prior to its utilization.

BACKGROUND As electronic health records have become a more integral part of a physician’s daily life, new electronic health record tools will continue to be rolled out to trainees. Patient access to provider notes is becoming a more widespread practice because this has been shown to increase patient empowerment. OBJECTIVE In this analysis, we compared differences between resident and attending physicians’ perceptions prior to implementation of patient access to provider notes to facilitate optimal use of electronic health record features and as a potential for patient empowerment. METHODS This was a single-site study within an academic internal medicine program. Prior to implementation of patient access to provider notes, we surveyed resident and attending physicians to assess differences in perceptions of this new electronic health record tool using an open access survey provided by OpenNotes. RESULTS We surveyed 37% (20/54 total) of resident physicians and obtained a 100% response rate and 72% (31/44 total) of attending physicians. Similarities between the groups included concerns about documenting sensitive topics and anticipation of improved patient engagement. Compared with attending physicians, resident physicians were more concerned about litigation, discussing weight, offending patients, and communicated less overall with patients through electronic health record. CONCLUSIONS Patient access to provider notes has the potential to empower patients but concerns of the resident physicians need to be validated and addressed prior to its utilization.

BackgroundWe evaluated how computerized clinical decision support (CDS) affects the counseling women receive when primary care physicians (PCPs) prescribe potential teratogens and how this counseling affects women's behavior.MethodsBetween October 2008 and April 2010, all women aged 18-50 years visiting one of three community-based family practice clinics or an academic general internal medicine clinic were invited to complete a survey 5-30 days after their clinic visit. Women who received prescriptions were asked if they were counseled about teratogenic risks or contraception and if they used contraception at last intercourse.ResultsEight hundred one women completed surveys; 27% received a prescription for a potential teratogen. With or without CDS, women prescribed potential teratogens were more likely than women prescribed safer medications to report counseling about teratogenic risks. However, even with CDS 43% of women prescribed potential teratogens reported no counseling. In multivariable models, women were more likely to report counseling if they saw a female PCP (odds ratio: 1.97; 95% confidence interval: 1.26-3.09). Women were least likely to report counseling if they received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Women who were pregnant or trying to conceive were not more likely to report counseling. Nonetheless, women who received counseling about contraception or teratogenic risks were more likely to use contraception after being prescribed potential teratogens than women who received no counseling.ConclusionsPhysician counseling can reduce risk of medication-induced birth defects. However, efforts are needed to ensure that PCPs consistently inform women of teratogenic risks and provide access to highly effective contraception.

Maintaining weight loss is a significant challenge in combating obesity. The goal of Maintaining Activity and Nutrition through Technology-Assisted Innovation in Primary Care (MAINTAIN-pc) is to evaluate the use of tools delivered through an electronic health record (EHR) and patient portal, with or without health coach support, to help primary care patients maintain weight loss. EHR tools include flowsheets, standardized surveys, and secure patient messaging. Inclusion criteria were age 18–75 years, voluntary 5% weight loss in the past 2 years with prior BMI ≥ 25 kg/m2, and no bariatric procedures in past 5 years. Participants were randomized 1:1 to tailored online coaching with EHR tracking tools (CC) or EHR tracking tools alone (TO). We screened 721 individuals between October 2013 and February 2015; 194 participants enrolled (98 CC; 96 TO). The most common reasons for not enrolling included lack of interest (56%), not meeting age or weight loss criteria (17%), and no verified prior weight loss (10%). At baseline, participants were 53.4 (SD 12.2) years old, 74% female, and 88% White; 95% reported moderate physical activity. Average weight and BMI at baseline were 189.1 (SD 42.1) lbs and 30.4 (5.9) kg/m2, respectively. Pre-weight loss BMI was 34.4 (SD 6.5) kg/m2. Participants lost an average of 11.3% (SD 6.6) of their body weight before enrolling. Demographic and clinical characteristics did not differ by randomized group. The study successfully identified and recruited primary care patients with recent voluntary weight loss for participation in a weight maintenance program that uses EHR-based tools.

The patient-centered medical home (PCMH), with its focus on patient-centered care, holds promise as a way to reinvigorate the primary care of patients and as a necessary component of health care reform. While its tenets have been the subject of review, the ethical dimensions of the PCMH have not been fully explored. Consideration of the ethical foundations for the core principles of the PCMH can and should be part of the debate concerning its merits. The PCMH can align with the principles of medical ethics and potentially strengthen the patient–physician relationship and aspects of health care that patients value. Patient choice and these ethical considerations are central and at least as important as the economic and practical arguments in support of the PCMH, if not more so. Further, the ethical principles that support key concepts of the PCMH have implications for the design and implementation of the PCMH. This paper explores the PCMH in light of core principles of ethics and professionalism, with an emphasis both on how the concept of the PCMH may reinforce core ethical principles of medical practice and on further implications of these principles.

Background Primary care physicians (PCPs) care for most non–dialysis-dependent patients with chronic kidney disease (CKD). Studies suggest that PCPs may deliver suboptimal CKD care. One means to improve PCP treatment of CKD is clinical decision support systems (CDSSs). Study Design Cluster-randomized controlled trial. Setting & Participants 30 PCPs in a university-based outpatient general internal medicine practice and their 248 patients with moderate to advanced CKD who had not been referred to a nephrologist. Intervention 2 CKD educational sessions were held for PCPs in both arms. The 15 intervention-arm PCPs also received real-time automated electronic medical record alerts for patients with estimated glomerular filtration rates 2 recommending renal referral and urine albumin quantification if not done within the prior year. Outcomes Primary outcome was referral to a nephrologist; secondary outcomes were albuminuria/proteinuria assessment, CKD documentation, optimal blood pressure (ie, Results The intervention and control arms did not differ in renal referrals (9.7% vs 16.5%, respectively; between-group difference, −6.8%; 95% CI, −15.5% to 1.8%; P = 0.1) or proteinuria assessments (39.3% vs 30.1%, respectively; between-group difference, 9.2%; 95% CI, −2.7% to 21.1%; P = 0.1). For intervention and control patients without a baseline proteinuria assessment, 27.7% versus 16.3%, respectively, had one at follow-up ( P = 0.06). After controlling for clustering, these findings were largely unchanged and no significant differences were apparent between groups. Limitations Small single-center university-based practice, use of a passive CDSS that required PCPs to trigger the electronic order set. Conclusions PCPs were willing to partake in a randomized trial of a CDSS to improve outpatient CKD care. Although CDSSs may have potential, larger studies are needed to further explore how best to deploy them to enhance CKD care.

Objective To examine patients’ perception of how a referral-based online lifestyle intervention contributed to primary care medicine. Methods We invited 50 adults to complete a semi-structured interview after a 1-year online behavioral weight loss intervention (average weight change: −4.79 kg). We developed an iterative codebook using content analysis. Two coders independently coded all transcripts (kappa = 0.895). We analyzed responses regarding the integration of the program with primary care. Results Among the 35 participants who completed the interview, 46% described a positive experience between the program and their routine medical care; 14% noted it was fine/OK; 9% reported no effect, 3% were negative, 11% said that the program was unrelated to their medical care, and 14% that the only connection was the referral. Factors such as physician feedback and support, coordination with routine health care, and improved cardiovascular risk factors were cited in support of a positive experience. Physician feedback was reported by 89%, and 80% stated that the program helped them to follow their physician's advice. Conclusion Physician referral to online education and counseling may facilitate the integration of evidence-based behavioral counseling with primary care. Practice implications Internet technology may enable improved access to evidence-based counseling for chronic health problems.

Doc.com© is the American Academy of Communication in Healthcare's web-based resource for learning core communication skills. To date, very few doc.com© modules have been evaluated formally. This study sought to assess four modules' effectiveness at improving internal medicine interns' communication skills knowledge. Interns were asked to complete four modules early in internship and complete web-based five-item pre/post multiple choice tests and a satisfaction survery for each module. The participation rate was 97 per cent (31 of 32 interns). Knowledge improved significantly with module completion (average pre-test score 89 per cent versus post-test 95 per cent, p = 0.006). Most (86 per cent) felt that the modules were clearly presented and met stated learning objectives, 67 per cent felt that completing the modules would improve their out-patient communication skills, and 62 per cent their inpatient skills. However, only 16 per cent indicated that the modules should replace faculty-led communicat...

The objective of this work was to rate the potential or actual usefulness of 15 features of a Web-based portal for diabetes management and assess whether patients would be willing to pay user fees for portal access. We used a combination of qualitative methods (focus group discussions) and quantitative methods (survey responses) to examine patients' perspectives. We enrolled 21 patients before the diabetes-specific portal was released ("preportal" group) and 18 patients after it was released ("portal-users" group). The two groups were similar except that 67% of preportal patients and 100% of portal users were Internet users. Overall, portal features that were rated most favorably were the online calculator to estimate blood glucose control (characterized as "very useful" by 74% of patients), appointment reminder systems (74%), e-mail access to health team (74%), personal tracking logs (69%), and online scheduling (69%). More patients from the preportal group than the portal-users group favored personal logs (86% versus 50%; p = 0.015) and opportunities to form interest groups (62% versus 28%; p = 0.034). Of the 30 patients who assigned a dollar amount for 1 month of portal access, 20 assigned zero dollars. Discussions about payment focused on equity and access. Because fees are expected to discourage portal usage, many patients believed that the potential benefits associated with self-management would not be realized. Others felt that the health system would benefit financially from a portal and should therefore absorb the costs. Even if portals are valued, patients may be resistant to paying for them. This opposition stems from concerns about fairness and from the recognition that health systems may experience cost savings if patients manage their diabetes successfully.

Purpose The purpose of this qualitative study was to explore perceptions of people with diabetes about their experience of living with and managing their diabetes. Methods This study was part of a larger study of patients with diabetes who used a novel computer portal system for access to information about diabetes and to their health care providers for enhanced communication. The research method used for this portion of the study was grounded theory methodology, a particular kind of qualitative research method. Results A central theme generated from the data was “normalizing an identity as a person with diabetes.” The participants described themselves as diabetic; they took on an identity in which having diabetes was central. They struggled with how to become “a person with diabetes” rather than a “diabetic person.” Conclusions For people who are diagnosed with diabetes, there is a struggle to become a person with diabetes rather than a diabetic person and to manage the lifestyle changes that are mandated by this role/identity. One way of dealing or coping with this new identity is to begin to “normalize” these lifestyle changes—to view them as healthy living for all people, those with and without diabetes. This will then have implications for interventions—encouraging healthy lifestyles among people with diabetes rather than emphasizing that people with diabetes are “different from” the general population.

Background Recruiting patients into clinical research protocols is challenging. Electronic medical record (EMR) systems capable of prompting clinicians may facilitate enrollment. Objective To compare an EMR-based clinician prompt versus a wait-room-based case-finding strategy at enrolling patients into a clinical trial. Design Cross-sectional comparison of recruitment data from two trials to treat anxiety disorders in primary care. Both studies utilized similar enrollment criteria, intervention strategies, and the same four practice sites and EMR system. Participants Patients referred by their (primary care physicians) PCPs in response to an EMR prompt (recruited 1/2005–10/2006), and patients enrolled by research assistants stationed in practice waiting rooms (7/2000–4/2002). Measurements Referral counts, patients’ baseline sociodemographic and clinical characteristics. Results Over a 22-month period, EMR-prompted PCPs referred 794 patients and 176 (22%) met study inclusion criteria and enrolled, compared to 8,095 patients approached by wait room-based recruiters of whom 193 (2.4%) enrolled. Subjects enrolled by EMR-prompted PCPs were more likely to be non-white (23% vs 5%; P

Patient-administered computerized questionnaires represent a novel tool to assist primary care physicians in the delivery of preventive health care.The aim of this study was to assess patient-reported ease of use with a self-administered tablet computer-based questionnaire in routine clinical care.All patients seen in a university-based primary care practice were asked to provide routine screening information using a touch-screen tablet computer-based questionnaire. Patients reported difficulty using the tablet computer after completion of their first questionnaire.Ten thousand nine hundred ninety-nine patients completed the questionnaire between January 2004 and January 2006.We calculated rates of reporting difficulty (no difficulty, some difficulty, or a lot of difficulty) using the tablet computers based on patient age, sex, race, educational attainment, marital status, and number of comorbid medical conditions. We constructed multivariable ordered logistic models to identify predictors of increased self-reported difficulty using the computer.The majority of patients (84%) reported no difficulty using the tablet computers to complete the questionnaire, with only 3% reporting a lot of difficulty. Significant predictors of reporting more difficulty included increasing age [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.05-1.05)]; Asian race (OR 2.3, 95% CI 1.8-2.9); African American race (OR 1.4, 95% CI 1.2-1.6); less than a high school education (OR 3.0, 95% CI 2.6-3.4); and the presence of comorbid medical conditions (1-2: OR 1.3, 95% CI 1.2-1.5;or =3: OR 1.7 95% CI 1.5-2.1).The majority of primary care patients reported no difficulty using a self-administered tablet computer-based questionnaire. While computerized questionnaires present opportunities to collect routine screening information from patients, attention must be paid to vulnerable groups.

Background Bioinformatics experts are developing interactive patient portals to help those living with diabetes and other chronic diseases to better manage their conditions. However, little is known about what influences patients’ desires to use this technology. Objective To discern the impact of the provider–patient relationship on interest in using a web-based patient portal. Design Qualitative analysis of focus groups. Participants Ten focus groups involving 39 patients (range 2–7) recruited from four primary care practices. Approach A qualitative approach was used, which involved reading transcribed texts until a consensus was reached on data interpretation. An intercoder reliability kappa score (0.89) was determined by comparing the provider–patient relationship talk selected by the two coders. A conceptual framework was developed, which involved the development and refinement of a codebook and the application of it to the transcripts. Results Interest in the portal was linked to dissatisfaction with the provider–patient relationship, including dissatisfaction with provider communication/responsiveness, the inability to obtain medical information, and logistical problems with the office. Disinterest in the portal was linked to satisfaction with the provider–patient relationship, including provider communication/responsiveness, difficulty in using the portal, and fear of losing relationships and e-mail contact with the provider. No patient identified encrypted e-mail communication through the portal as an advantage. Conclusions Promoting the use of computerized portals requires patient-based adaptations. These should include ease of use, direct provider e-mail, and reassurances that access and interpersonal relationships will not be lost. Education is needed about privacy concerns regarding traditional e-mail communication.

The University of Pittsburgh Medical Center (UPMC) has implemented a personal health record grounded in the Chronic Care Model, UPMC HealthTrak, to assist patients with diabetes self-management. UPMC HealthTrak is based in the physician office and connects the patient, physician, and electronic medical record (EMR). Its functionalities include secure, electronic communication with the physician's office, along with preventive healthcare reminders, and disease-specific tools and information. In this paper, we describe challenges to office-based implementation of and initial patient reaction to the technology in the context of diabetes care. UPMC has deployed a secure Web-based patient portal, UPMC HealthTrak. We implemented UPMC HealthTrak in the ambulatory setting and assessed its impact on patient-practice communication. We conducted 10 90-minute focus groups (five pre- and five postimplementation) to assess patient reaction to UPMC HealthTrak. Focus groups were analyzed using grounded theory techniques. During the period September 2004-January 2007, there was no significant change in number of patient encounters or telephone calls received in our office, but the number of HealthTrak messages increased. Our 39 pre- and postimplementation focus group participants felt that the system would enhance communication with the office, and that the reminder system would be helpful. They also liked having access to laboratory tests remotely. They were frustrated when tests were not released and messages not answered. A Web-based patient portal can be integrated into a clinical office, although patients may not quickly change communication patterns. Patients are responsive to technology. Future work should focus on diabetes-related outcomes assessment and intensifying interventions.

In Brief This article describes the recent development of a diabetes-specific patient portal that is linked to an existing electronic medical record system. The portal was designed to provide patients with a secure means of electronic access to preventive health care reminders, information concerning their medications and health histories, educational materials, and self-management resources concerning diabetes-related risks. The authors briefly describe their work on the portal to date and discuss future directions for their research.

BACKGROUND Advance directives (AD) with specific treatment preferences can be difficult to apply in actual clinical situations. As an alternative, advance directives that outline patient goals and values have been advocated.

Discussing advance care plans with elderly patients can improve the experience of end-of-life care for patients, families, and health care teams. Specific goals for any particular discussion should be based on patients' particular clinical circumstances. Physicians should focus on patients' overall values and goals and should provide emotional support during the discussion. Decisions made during the advance care planning process should be documented.

Background UPP-GIM, a large urban academic primary-care practice and a patient-centered medical home, treats approximately 1800 diabetics. Despite multiple interventions, the number of patients with A1C=9% remained at 14%, and dilated retina exam (DRE) rate was only 64%. Objectives 1. Create a comprehensive team-based model that engages patients throughout their continuum of care, focusing on patients with A1C=9%. 2. Incrementally improve glycemic control, diabetes outcomes and DRE rate. Methods In January 2014, a multi-disciplinary diabetes team was created to redesign care. A comprehensive care model was established and implemented in phases. All clinic staff and physicians participated. It included engaging patients with a pre-visit phone call, improving at-visit efficiency to maximize addressing all patient needs, including downloading and printing glucose meter reports and adding tele-ophthalmology, and intensifying inter-visit care with algorithm-based medication titration. (see figure) Processes and outcomes were tracked over 18 months. Control charts were used to evaluate processes and outcome measures as phases were implemented and quarterly reports for outcomes. Results Mean A1C in the cohort of patients starting with A1C=9% (n=246) improved from 10.8 (±1.7) to 9.5 (±1.9). Appointment show rate improved from 68% to 73%.Encounters with diabetic educators rose from 20% to 54%. Meter download compliance reached almost 90% and DRE rates improved from 64% to 76%. Conclusions Engaging uncontrolled diabetic patients before, during, and after visits with a team-based approach and novel day-of-visit efficiencies improved glycemic control and eye exam rates. Continued monitoring is needed to ensure the durability of these gains.

OBJECTIVE: To determine patient knowledge about life-sustaining treatments and physician understanding of patient preferences for proxies and treatments after outpatient discussions about advance directives. DESIGN: Cross-sectional interview-based and questionnaire-based survey. SETTING: Two university general internal medicine practices, two Department of Veterans Affairs general internal medicine practices, and one university-based geriatrics practice, in two different cities. PATIENTS: Fifty-six patients of primary care internists. INTERVENTION: Physicians discussed “advance directives” (ADs) with one randomly selected patient during an outpatient visit. MEASUREMENTS AND MAIN RESULTS: After the discussions, physicians identified the patient’s proxy and predicted the patient’s preferences for treatment in 20 scenarios. Patients provided treatment preferences in the 20 scenarios, the name of their preferred surrogate decision maker, and their understanding of cardiopulmonary resuscitation and mechanical ventilation. Of the 39 patients who discussed resuscitation, 43% were able to identify two important characteristics; 26% identified none; 66% did not know that most patients need mechanical ventilation after undergoing resuscitation. None of the 43 patients who had a discussion about mechanical ventilation had a good understanding of it; 67% did not know that patients generally cannot talk while on ventilators; 46% expressed serious misconceptions about ventilators. There was poor agreement between physicians and their patients regarding treatment preferences in 18 of 20 scenarios (κ −0.04 to 0.31). Physicians correctly identified the proxy 89% of the time (κ 0.78). CONCLUSIONS: Patients leave routine AD discussions with serious misconceptions about life-sustaining treatments. Physicians are unable to predict treatment preferences but do learn about patients’ preferences for surrogate decision makers.

The patient-centered care (PCC) model and the use of health information technology (HIT) are major initiatives for improving U.S. healthcare quality and delivery. A lack of published data on patient perceptions of Internet-based care makes patient-centered implementation of HIT challenging. To help ascertain patients' perceptions of an online intervention, patients completing a 1-year web-based lifestyle intervention were asked to complete a semistructured interview. We used qualitative methodology to determine frequency and types of interview responses. Overall satisfaction with program features was coded on a Likert-type scale. High levels of satisfaction were seen with the online lifestyle coaching (80%), self-monitoring tools (57%), and structured lesson features (54%). Moderated chat sessions and online resources were rarely used. Frequently identified helpful aspects were those that allowed for customized care and shared decision-making consistent with the tenets of PCC. Unhelpful program aspects were reported less often. Findings suggest that despite challenges for communicating effectively in an online forum, the personalized support, high-tech data management capabilities, and easily followed evidence-based curricula afforded by HIT may be a means of providing PCC and improving healthcare delivery and quality.

Keeping patients with complex medical illnesses up to date with their preventive care and chronic disease management services, such as lipid testing and retinal exam in patients with diabetes, is challenging. Within a commercially available electronic health record (EHR) with a secure personal health record (PHR), we developed a system that sends up to three weekly reminders to patients who will soon be due for preventive care services. The reminder messages reside within the secure PHR, which is linked to the EHR, and are displayed on a screen where patients can also send to the physician's office an electronic message to request appointments for the needed services. The reminder messages stop when the patient logs on to review the reminders. The system, designed with patient input, groups together all services that will be due in the next 3 months to avoid repeatedly messaging the patient. After 2 months, the cycle of reminders begins again. This system, which is feasible and economical to build, has the potential to improve care and compliance with quality measures.

Phronesis, or practical wisdom developed through experience, is an Aristotelian concept that can shed light on the capacities of patients to make health-related decisions and engage in healthy behaviors. In this article, the authors develop a conceptual framework for understanding the role of phronesis in lifestyle change as well as its relationship to patient activation, which is considered to be a critical component of the Chronic Care Model and patient education in general. The authors develop the concept of phronesis by analyzing qualitatively the comments made by 35 participants working to manage chronic health issues in a weight-loss study. The authors iteratively coded transcribed passages of exit interviews for phronesis and patient activation. These passages provide experientially grounded content for evaluating the use of phronesis and its development among individuals engaging in lifestyle change. Phronesis is expressed in 31% of participant responses to questions regarding the relationship between the online lifestyle intervention, participant health, and participant readiness to engage in productive clinical encounters with health care practitioners. Of those responses, 73% express some level of patient activation. The authors conclude that phronesis may be an important new tool for understanding successful self-management support, with potential usefulness in the creation of tailored lifestyle interventions, the development of patient activation, and the ability of participants to enact health-related behaviors.

BACKGROUND: Traditionally, behavioral lifestyle programs have been delivered in person with adherence defined as number of sessions attended. With growing use of online interventions, an understanding of how to assess and enhance adherence to such programs is needed. In this analysis, we examine: 1) measures of adherence to an online lifestyle program; 2) how measures differ from month 6 to month 12 of an 18-month program; and 3) predictors of continued active status. METHODS: The Pittsburgh-Hershey Internet-based Translation (PHIT) study is an online adaptation of the Diabetes Prevention Program delivered in coordination with primary care. We recruited 124 patients; 61 were randomized to an 18-month online intervention, including lessons; weight, diet, and physical activity (PA) self-monitoring; and feedback from a lifestyle coach. A participant is inactive when he/she has not logged in for ≥28 days or responded to phone calls. We abstracted program use data as potential adherence measures: active/inactive status, log-in in past 7 days, self-monitoring, and number of lessons completed. Potential predictors of active status included sociodemographic variables, computer skill, and baseline BMI. Differences between 6- and 12-month measures were calculated with t-test or Wilcoxan rank test. Predictors of active status were determined with logistic regression. RESULTS: Of 61 participants in the intervention group, 42 (69%) were women, 54 (89%) were white, and 30 (49%) had college degree or higher. At 6 months, 29 (45%) of participants were active in the program. Eighteen (30%) had log-in, 13 (26%) posted a weight , and 11 (18%) self-monitored diet and PA in past 7 days. All measures of adherence declined at 12 months, although only active status (with 17 (28%) active) was significantly lower (p=0.03) than 6 months. At 12 months, 9 (15%) had a log-in, 7 (12%) posted a weight, 7 (12%) self-monitored diet and PA in past 7 days. At 6 months, participants had completed an average of 7.5 (SD 6.2) of 16 expected lessons; at 12 months, participants had completed an average of 9.2 (SD 8.3) lessons of 24 expected lessons. None of the variables considered predicted active status at 6 months. At 12 months, men were four times as likely as women to be active (OR=3.8; p=0.03). Participants with higher baseline BMI (OR=0.88; p=0.04) and difficulty paying for basics (OR=0.12; p=0.04) were less likely to be active at 12 months. Age, education and computer skill did not predict active status at either time point. CONCLUSION: Active status declined significantly between 6 and 12 months and use of online self-monitoring tools was low at both time points. Females, heavier persons, and those with financial constraints may need additional support to stay engaged. Future research should address how measures of adherence relate to program outcomes such as weight loss and how to improve adherence to online interventions over time.

Potentially teratogenic medications are frequently prescribed without provision of contraceptive counseling.To evaluate whether computerized clinical decision support (CDS) can increase primary care providers' (PCPs') provision of family planning services when prescribing potentially teratogenic medications.Cluster-randomized trial conducted in one academic and one community-based practice between October of 2008 and April of 2010.Forty-one PCPs were randomized to receive one of two types of CDS which alerted them to risks of medication-induced birth defects when ordering potentially teratogenic medications for women who may become pregnant. The 'simple' CDS provided a cautionary alert; the 'multifaceted' CDS provided tailored information and links to a structured order set designed to facilitate safe prescribing. Both CDS systems alerted PCPs about medication risk only once per encounter.We assessed change in documented provision of family planning services using data from 35,110 encounters and mixed-effects models. PCPs completed surveys before and after the CDS systems were implemented, allowing assessment of change in PCP-reported counseling about the risks of medication-induced birth defects and contraception.Both CDS systems were associated with slight increases in provision of family planning services when potential teratogens were prescribed, without a significant difference in improvement by CDS complexity (p = 0.87). Because CDS was not repeated, 13% of the times that PCPs received CDS they substituted another potential teratogen. PCPs reported significant improvements in several counseling and prescribing practices. The multifaceted group reported a greater increase in the number of times per month they discussed the risks of medication use during pregnancy (multifaceted: +4.9 ± 7.0 vs. simple: +0.8 ± 3.2, p = 0.03). The simple CDS system was associated with greater clinician satisfaction.CDS systems hold promise for increasing provision of family planning services when fertile women are prescribed potentially teratogenic medications, but further refinement of these systems is needed.

Background Chronic kidney disease (CKD) is a common disorder associated with increased morbidity and mortality. Primary care physicians (PCPs) care for the majority of pre-dialysis CKD patients; however, PCPs often do not recognize the presence of CKD based on serum creatinine levels. Prior studies suggest that PCPs and nephrologists deliver suboptimal CKD care. One strategy to improve disease awareness and treatment is estimated glomerular filtration rate (eGFR) reporting. We examined PCP and nephrologist CKD practices before and after routine eGFR reporting. Methods We conducted a retrospective cohort study of patients with CKD 3b-4 (eGFR < 45) seen at a university-based, outpatient primary care clinic. Using a chi-square or Fisher's exact test, we compared co-management rates, renal protective strategies, CKD documentation, and laboratory processes of care in 274 patients and 266 patients seen in a 6-month period prior to and following eGFR implementation, respectively. Results CKD co-management increased from 22.6% pre-eGFR to 48.5% post-eGFR (P < 0.0001). eGFR reporting did not improve angiotensin converting enzyme inhibitor or angiotensin receptor blocker use or quantitative urinary testing. However, non-steroidal anti-inflammatory drug avoidance (pre-eGFR 81.8% vs. post- eGFR 90.6%, P = 0.003) and phosphorus and parathyroid hormone testing improved (pre-eGFR vs. post-eGFR: 32.5% vs. 51.5%, P < 0.0001; 12.4% vs. 36.1%, P < 0.0001 respectively). Conclusions A marked increase in CKD co-management was observed following eGFR implementation. Although some improvements in processes of care were noted, this did not include angiotensin converting enzyme inhibitor or angiotensin receptor blocker use. Overall care remained suboptimal despite eGFR reporting; further strategies are needed to improve PCP and nephrologist CKD care.

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

Despite evidence-based recommendations for addressing obesity in the clinical setting, lifestyle interventions are lacking in practice. The objective of this study was to translate an evidence-based lifestyle program into the clinical setting by adapting it for delivery via the Internet. We adapted the Diabetes Prevention Program's lifestyle curriculum to an online format, comprising 16 weekly and 8 monthly lessons, and conducted a before-and-after pilot study of program implementation and feasibility. The program incorporates behavioral tools such as e-mail prompts for online self-monitoring of diet, physical activity, and weight, and automated weekly progress reports. Electronic counseling provides further support. Physician referral, automated progress reports, and as-needed communication with lifestyle coaches integrate the intervention with clinical care. We enrolled 50 patients from a large academic general internal practice into a pilot program between November 16, 2006 and February 11, 2007. Patients with a body mass index (BMI) =25 kg/m2, at least one weight-related cardiovascular risk factor, and Internet access were eligible if referring physicians felt the lifestyle goals were safe and medically appropriate. Participants were primarily female (76%), with an average age of 51.94 (standard deviation [SD] 10.82), and BMI of 36.43 (SD 6.78). At 12 months of enrollment, 50% of participants had logged in within 30 days. On average, completers (n = 45) lost 4.79 (SD 8.55) kg. Systolic blood pressure dropped 7.33 (SD 11.36) mm Hg, and diastolic blood pressure changed minimally (+0.44 mm Hg; SD 9.27). An Internet-based lifestyle intervention may overcome significant barriers to preventive counseling and facilitate the incorporation of evidence-based lifestyle interventions into primary care.

This report describes a novel 3-hour workshop on delivering bad news and discussing end-of-life goals of care for internal medicine interns, and its effect on the interns' attitudes, knowledge, and confidence in discussing these topics with patients.Interns participated in a 3-hour workshop involving role-playing, focused on teaching core knowledge, skills, and attitudes associated with delivering bad news and discussing goals of care at the end of life.One to 3 weeks before and after the workshop, participants completed a written questionnaire that included 54 knowledge questions, 6 questions eliciting their perceived level of confidence, and 11 questions about attitudes toward delivering bad news or discussing goals of care. Immediately after the workshop, interns answered questions rating their satisfaction with the workshop.Of 43 interns who took the pretest, 29 completed the posttest. There was a high degree of satisfaction with the workshop. Mean knowledge scores increased by 4 points (from 41.4 to 45.4, p0.001). The percentage of interns who expressed confidence increased. There was no change in interns' attitudes.

Identifying objectives for advance care planning (ACP) is an important step toward improving care at the end of life. Previous studies of ACP have used many different measures of success. However, there has been no consensus on what should be the objectives for ACP. Lack of attention to specific objectives for ACP may lead to ineffective communication and research. The first step to improving outcomes in ACP is to acknowledge the diversity of objectives that ACP may achieve. Health care providers, patients, and surrogates should identify and agree on common objectives for particular conversations. Various methods, conversations, and forms may be used to achieve these objectives over time. Clarifying objectives from various perspectives is an important step toward achieving the level of understanding necessary to make these difficult decisions. It is time for physicians to reconsider the way in which they think about and discuss ACP with patients. If we are to improve care at the end of life, future patient care, research, and education about ACP should proceed with specific objectives in mind.

Advance directives (ADs) are widely regarded as the best available mechanism to ensure that patients' wishes about medical treatment at the end of life are respected. However, observational studies suggest that these discussions often fail to meet their stated goals.To explore best practices by describing what physicians who are considered expert in the area of end of-life bioethics or medical communication do when discussing ADs with their patients and to explore the ways in which best practices of the expert group might differ in content or style from normative practice derived from primary care physicians' discussions of ADs with their patients collected as part of an earlier study.Nonexperimental, descriptive study of audiotaped discussions.Outpatient primary care practices in the United States.Eighteen internists who have published articles in the areas of bioethics or communication and 48 of their patients. Fifty-six academic internists and 56 of their established patients in 5 practice sites in 2 locations-Durham, NC, and Pittsburgh, Pa. Eligible patients were at least 65 years old or suffered from serious medical illness and had not previously discussed ADs with their physician. Expert clinicians had discretion regarding patient selection, while the internists chose patients according to a predetermined protocol.Coders applied the Roter Interaction Analysis System (RIAS) to audiotapes of the medical visits to describe communication dynamics. In addition, the audiotapes were scored on 21 items reflecting physician performance in specific skills related to AD discussions.Experts spent close to twice as much time (14.7 vs 8.1 minutes, P.001) and were less verbally dominant (P.05) than other physicians during AD discussions. When length of visit was controlled statistically, the expert physicians gave less information about treatment procedures and biomedical issues (P.05) and asked fewer related questions (P. 05) but tended toward more psychosocial and lifestyle discussion and questions. Experts engaged in more partnership building (P.05) with their patients. Patients of the expert physicians engaged in more psychosocial and lifestyle discussion (P.001), and more positive talk (P.05) than patients of community physicians. Expert physicians scored higher on the 21 items reflecting AD-specific skills (P.001).Best practices as reflected in the performance of expert physicians reflect differences in measures of communication style and in specific AD-related proficiencies. Physician training in ADs must be broad enough to include both of these domains. Arch Intern Med. 2000;160:3477-3485.