Initiation of health behavior discussions during primary care outpatient visits

Objective

Despite the importance of health promotion, rates of health behavior advice remain low and little is known about how advice is integrated into routine primary care. This study examines how health behavior topics of diet, physical activity and smoking are initiated during outpatient visits.

Methods

Audio recording of 187 adults visit to five purposefully selected physicians. An iterative analysis involved listening to and discussing cases to identify emergent patterns of initiation of health behavior talk and advice that followed.

Results

Physicians initiated 65% of discussions and used two overarching strategies (1) Structured: a routine to ask about health behavior and (2) Opportunistic: use of a trigger to make a transition to talk about health behavior. Opportunistic strategies identified a greater proportion of patients at risk (50% vs. 34%) and led to a greater rate of advice (100% vs. 75%). Patients initiated one-third of health behavior discussions and were more likely to receive advice if they explicitly indicated readiness to change.

Conclusions

Opportunistic strategies show promise for a higher yield of identifying patients at risk and leading to advice.

Practice Implications

Encouraging patients to be explicit about their readiness to change is likely to increase physician advice and assistance.     

Evaluation of a patient-centered after visit summary in primary care

Objective

To test the impact of a redesigned, patient-centered after visit summary (AVS) on patients’ and clinicians’ ratings of and experience with the document.

A scoping review of communication tools applicable to patients and their primary care providers after discharge from hospital

ObjectiveTransitions from hospital to home are high-risk episodes. Communication problems between patients/carers and their primary healthcare providers are a central part of the risk. This literature review aimed to identify any existing tools or information (including secondary care instruments) that would facilitate designing new communication instruments for primary care to manage and mitigate risk at discharge.MethodFive databases (Pubmed, Embase, Cinahl, Web of Science and Cochrane) were searched using a three stem approach (primary/transitional care, discharge period, communication). A dual reviewer system was used, following PRISMA guidelines.ResultsFrom 61 full text articles a total of ten tools were found, 25 articles contained other useful content, 19 further tools were found in grey literature. Most material originated from the USA and described hospital-based transitional care interventions.ConclusionNo ready-made patient/provider communication tool for the post-discharge period in primary care was found. Future communication tools should enhance education and engagement of patients so they feel able to initiate communication.Practice implicationsCollating post-discharge communication material is of importance to improving the safety of care transitions and will enable creation of new tools specifically designed for primary care. These tools will improve patient activation (‘the knowledge, skills and confidence a person has in managing their own health and care’) with the ultimate aim of reducing error and harm in primary care through improved communication of healthcare decisions.     

Enhancing delivery of health behaviour change interventions in primary care: a meta-synthesis of views and experiences of primary care nurses

Objective

To systematically find and synthesise qualitative studies that elicited views and experiences of nurses involved in the delivery of health behaviour change (HBC) interventions in primary care, with a focus on how this can inform enhanced delivery and adherence to a structured approach for HBC interventions.

Methods

Systematic search of five electronic databases and additional strategies to maximise identification of studies, appraisal of studies and use of meta-synthesis to develop an inductive and interpretative form of knowledge synthesis.

Results

Nine studies met the inclusion criteria. Synthesis resulted in the development of four inter-linking themes; (a) actively engaging nurses in the process of delivering HBC interventions, (b) clarifying roles and responsibilities of those involved, (c) engaging practice colleagues, (d) communication of aims and potential outcomes of the intervention.

Conclusion

The synthesis of qualitative evidence resulted in the development of a conceptual framework that remained true to the findings of primary studies. This framework describes factors that should be actively promoted to enhance delivery of and adherence to HBC interventions by nurses working in primary care.

Practice implications

The findings can be used to inform strategies for researchers, policymakers and healthcare providers to enhance fidelity and support delivery of HBC interventions.     

Development of an electronic pictorial asthma action plan and its use in primary care

Objective

Self-management education and the issuing of a written action plan improve outcomes for asthma. Many do not receive a plan and some cannot use the written word. We have developed an electronic pictorial asthma action plan (E-PAAP).

Methods

A pictorial action plan was incorporated into a software package. 21 general practices were offered this tool and the software was loaded onto 63 desktop computers (46 GPs and 17 nurses). Usage was assessed and health care professionals questioned as to its use.

Results

190 plans had been printed in a 4-month period (17 for test purposes). The individual usage rate ranged from 0 to 28 plans. Doctors printed 73% (139/190) a mean of 3 per doctor and nurses printed 27% a mean of 2 per nurse (37/190). Excluding the test copies, 116/173(67%) were printed as picture and text together.

Conclusion

Nearly half of all healthcare professionals used the E-PAAP software. Usage was skewed with some individuals using the software significantly more than others. The software package should help overcome problems of access to paper templates, by calculating peak flow action thresholds and by prompting correct completion. Barriers to the use of asthma action plans, such as perceived time constraints, persist.

Practice implications

The development of an electronic asthma action plan facilitates health professional access to a basic template and prompts the user as to correct usage. It is to be hoped that such facilitation enhances the number of action plans issued and in this study GPs were greater users than the nurses.     

The effects of self-management education tailored to health literacy on medication adherence and blood pressure control among elderly people with primary hypertension: A randomized controlled trial

ObjectiveTo evaluate the effects of self-management education tailored to health literacy on medication adherence and blood pressure control.MethodThis randomized controlled trial was conducted in 2018 with 118 elderly people with uncontrolled primary hypertension and inadequate health literacy. Self-management education was developed on the basis of the health literacy index. Medication adherence and blood pressure were assessed using 8-items Morisky Medication Adherence Scale and a mercury sphygmomanometer, respectively.ResultsAt baseline, there were no significant between-group differences regarding participants’ demographic characteristics, medical history, and medication adherence. After the intervention, between-group comparisons adjusted for pretest scores showed a significant reduction in the mean score of systolic and diastolic blood pressure and increase adherence to medication due to intervention (P < 0.05). However, the proportions of controlled systolic and diastolic blood pressure were not statistically significant different between-group (P > 0.05).ConclusionSelf-management education tailored to health literacy significantly promotes medication adherence but has no significant effects on control of blood pressure.Practice implicationTo promote adherence to antihypertensive medications, tailored patient education to Health literacy is recommended. Limited pieces of evidence are available on the effectiveness of health literacy index-based interventions, so further studies are required.     

Patients' responsiveness to a decision support tool for primary prevention of cardiovascular diseases in primary care

OBJECTIVE: Assessment of patients' responsiveness to a decision support tool for primary prevention of cardiovascular diseases (CVDs). The booklet focuses on barriers at patient level. METHODS: Process evaluation of an intervention in primary care. Patients at high or potentially high-cardiovascular risk were asked by their GP to prepare themselves for a second consultation in order to participate in decisions on risk management. OUTCOMES: Patients' actually having read the booklet and returning for the second consultation; comprehension and perceived relevance of the information; perceived reassurance. RESULTS: 17 GPs, in the intervention arm of a cluster RCT, issued 276 decision support tools during the first consultation and were instructed to ask them to return for a second consultation to discuss their CVD risk. Patients had a mean age of 54 years, 47% were male and 19% actually had a high cardiovascular risk. Data on 239 patients, a mixture of returnees and non-returnees, showed that they all read the booklet; comprehension was fair to good; 85% perceived the information as relevant; 68% of the patients felt reassured by the information. Satisfaction with the first consultation was higher in the non-returnees. CONCLUSIONS: Cardiovascular prevention spread over two consultations with use of a decision support tool for patients is not easily applicable for GPs. However, based on the findings of good patients' responsiveness, we recommend further development and implementation of decision support tools in primary care. PRACTICE IMPLICATIONS: Decision support for primary CV-prevention is welcomed by patients but needs further adjustment of both the GP and the organization of CV-prevention in primary care. Sharing information between professional and patient on a personal CV-risk management plan is difficult, more training is needed.     

Comorbidity of generalized social anxiety disorder and depression in a pediatric primary care sample

Background: Comorbidity between adult social anxiety disorder and major depression is extensive. Considerably less information about this relationship is available among youth. Methods: A randomly selected (from enrollees in a pediatric primary care clinic) sample of 190 families with children between the ages of 8 and 17 responded by mail to questionnaires assessing social anxiety, depression, and social functioning. Parents also completed a semi-structured telephone diagnostic interview about their child. Results: The generalized type of social anxiety disorder was highly comorbid with major depression, generalized anxiety disorder, specific phobias, and ADHD, while little comorbidity was present for the nongeneralized subtype of social anxiety disorder. Logistic regression analyses indicated that generalized social anxiety disorder was the only anxiety disorder associated with an increased likelihood of major depression (OR=5.1). In all cases, social anxiety disorder had a significantly earlier age of onset than major depression. Limitations: This study relies on cross-sectional data and diagnoses are based on parent reporting of child behavior. Conclusions: Generalized social anxiety disorder is strongly associated with depressive illness in youth. Screening and treatment approaches that consider both social anxiety and depressive symptoms are necessary. Early intervention to treat social anxiety disorder may prevent later depressive disorders.     

Identifying teachable moments for health behavior counseling in primary care

Objective

Situations with potential to motivate positive change in unhealthy behavior have been called ‘teachable moments’. Little is known about how they occur in the primary care setting.

Methods

Cross-sectional observational design. Audio-recordings collected during 811 physician–patient interactions for 28 physicians and their adult patients were analyzed using conversation analysis.

Results

Teachable moments were observed in 9.8% of the cases, and share three features: (1) the presence of a concern that is salient to the patient that is either obviously relevant to an unhealthy behavior, or through conversation comes to be seen as relevant; (2) a link that is made between the patient's salient concern and a health behavior that attempts to motivate the patient toward change; and (3) a patient response indicating a willingness to discuss and commit to behavior change. Additionally, we describe phenomena related to, but not teachable moments, including teachable moment attempts, missed opportunities, and health behavior advice.

Conclusions

Success of the teachable moment rests on the physician's ability to identify and explore the salience of patient concerns and recognize opportunities to link them with unhealthy behaviors.

Practice implications

The skills necessary for accomplishing teachable moments are well within the grasp of primary care physicians.     

Reliability and validity of a single-item rating scale to monitor medication adherence for people living with HIV and lower health literacy

Background:

Monitoring medication adherence in clinical and research settings may be especially challenging for people with lower literacy skills.

Objective:

The current study examined the measurement properties of a single-item rating scale (SIRS) for assessing medication adherence in a sample of 468 people living with HIV and lower health literacy skills.

Methods:

Participants completed two versions (computerized and telephone interview) of an SIRS as well as unannounced monthly pill counts. We also collected measures of common correlates of adherence and obtained participants' HIV RNA viral load from medical records.

Results:

Results indicated that the SIRS is time stable over one month (r?=?0.46 to 0.52). There was limited evidence for modality effects between the computerized and phone administered SIRS. Associations with unannounced pill counts demonstrated concurrent and predictive validity of the SIRS, and criterion-related validity by associations with viral load. However, the SIRS also demonstrated inflated adherence estimates relative to unannounced pill counts and these discrepancies were greatest for persons of lower income and who reported alcohol use.

Conclusions:

A simple SIRS to monitor medication adherence may therefore be reliable and valid for use with people challenged by lower literacy skills in both clinical and research settings.     

The role of coping in depression treatment utilization for VA primary care patients

Objective

To examine the impact of Veterans’ coping strategies on mental health treatment engagement following a positive screen for depression.

Methods

A mixed-methods observational study using a mailed survey and semi-structured interviews. Sample included 271 Veterans who screened positive for depression during a primary care visit at one of three VA medical centers and had not received a diagnosis of depression or prescribed antidepressants 12 months prior to screening. A subsample of 23 Veterans was interviewed.

Results

Logistic regression models showed that Veterans who reported more instrumental support and active coping were more likely to receive depression or other mental health treatment within three months of their positive depression screen. Those who reported emotional support or self-distraction as coping strategies were less likely to receive any treatment in the same time frame. Qualitative analyses revealed that how Veterans use these and other coping strategies can impact treatment engagement in a variety of ways.

Conclusions

The relationship between Veterans’ use of coping strategies and treatment engagement for depression may not be readily apparent without in-depth exploration.

Practice implications

In VA primary care clinics, nurse care managers and behavioral health providers should explore how Veterans’ methods of coping may impact treatment engagement.     

A method to determine the impact of patient-centered care interventions in primary care

Objective

The implementation of patient-centered care (PCC) innovations continues to be poorly understood. We used the implementation effectiveness framework to pilot a method for measuring the impact of a PCC innovation in primary care practices.

Methods

We analyzed data from a prior study that assessed the implementation of an electronic geriatric quality-of-life (QOL) module in 3 primary care practices in central North Carolina in 2011–2012. Patients responded to the items and the subsequent patient–provider encounter was coded using the Roter Interaction Analysis System (RIAS) system. We developed an implementation effectiveness measure specific to the QOL module (i.e., frequency of usage during the encounter) using RIAS and then tested if there were differences with RIAS codes using analysis of variance.

Results

A total of 60 patient–provider encounters examined differences in the uptake of the QOL module (i.e., implementation-effectiveness measure) with the frequency of RIAS codes during the encounter (i.e., patient-centeredness measure). There was a significant association between the effectiveness measure and patient-centered RIAS codes.

Conclusion

The concept of implementation effectiveness provided a useful framework determine the impact of a PCC innovation.

Practice implications

A method that captures real-time interactions between patients and care staff over time can meaningfully evaluate PCC innovations.     

Analysis of the relationship among health awareness and health literacy,patient satisfaction levels with primary care in patients admitting to primary care health centers

Objective

The aim of the study was to examine the relationships between health literacy, primary care satisfaction levels and health awareness of the patients who were admitted to primary care centers (Family Health Centers).

Older people's preferences for involvement in their own care: a qualitative study in primary health care in 11 European countries

OBJECTIVE: The aim of the study was to explore the views of people aged over 70 years on involvement in their primary health care in 11 different European countries. METHODS: Older patients were asked about their views on patient involvement in a face-to-face interview. All interviews were audio-recorded, transcribed and analysed in accordance with the principles of 'qualitative content analysis'. An international code list was used. RESULTS: Four hundred and six primary care patients aged between 70 and 96 years were interviewed. Their views could be categorized into four major groups: doctor-patient interaction, GP related topics, patient related issues and contextual factors. CONCLUSION: People over 70 do want to be involved in their care but their definition of involvement is more focussed on the 'caring relationship', 'person-centred approach' and 'receiving information' than on 'active participation in decision making'. PRACTICE IMPLICATIONS: The desire for involvement in decision making is highly heterogeneous so an individual approach for each patient in the ageing population is needed. Future research and medical education should focus on methods and training to elicit older patients' preferences. The similar views in 11 countries suggest that methods for enhancing patient involvement in older people could be internationally developed and exchanged.