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Table of Contents

March/April 2016; Volume 14,Issue 2

The Issue in Brief

Practical Opportunities for Healthy Diet and Physical Activity: Relationship to Intentions, Behaviors, and Body Mass Index

Robert L. Ferrer , and colleagues

Background Diet and activity choices emerge from what people find feasible to do in their daily lives. When there are few opportunities, people often adjust their expectations downward. This study sets out to a) confirm a method of measuring practical opportunities for healthy diet and physical activity, and b) evaluate the utility of this new tool to understand the contexts for people's health behavior choices.

What This Study Found Practical opportunities for healthy diet and physical activity are measurable and predict behavioral intentions, diet quality, activity minutes and body mass index.

Implications

  • These findings underline the need to understand the complexity of people's lives as part of promoting healthy behaviors.
  • Assessing opportunities in health behavior management could lead to more effective, efficient and respectful interventions.

General Practitioners' Empathy and Health Outcomes: A Prospective Observational Study of Consultations in Areas of High and Low Deprivation

Stewart W. Mercer , and colleagues

Background Primary care has the potential to help reduce health inequalities but there has been little research on patients' expectations and the characteristics of doctor visits in differing socioeconomic areas. This study compares general practitioner visits in areas of high and low deprivation in Scotland and analyzes factors that predict poorer or better outcomes in both low and high socioeconomic groups.

What This Study Found Compared with affluent areas, patients in deprived areas have higher rates of ill health, psychosocial problems, and multimorbidity; more problems to discuss within the same visit time yet less desire for shared decision making; perceive their GPs as less empathetic; and have worse outcomes at one month. Physicians in deprived areas display verbal and nonverbal behaviors that are less patient-centered. Perceived physician empathy is the only visit factor that predicts better outcomes in patient symptoms and wellbeing in both high- and low-deprivation groups.

Implications

  • To improve health in deprived areas, the authors call for policies that address wider social determinants of health and improve consultation quality.

Advance Care Planning Meets Group Medical Visits: The Feasibility of Promoting Conversations

Hillary D. Lum , and colleagues

Background Primary care needs new models to facilitate advance care planning conversations. This study describes a pilot demonstration of a group visit for advance care planning that engages patients in detailed conversations by providing a safe and supportive environment.

What This Study Found Group visits offer a feasible approach for facilitating discussions about advance care planning. Most participants evaluated the group visit as better than usual clinic visits for discussing advance care planning. After two 90-minute sessions, patients reported increases in detailed advance planning conversations. Participants were willing to share personal values and challenges related to advance care planning and initiated discussions about a broad range of related topics.

Implications

  • The authors conclude the model warrants further evaluation for effectiveness in improving advance care planning outcomes for patients, clinicians and the health care system.

Electronic Consultations to Improve the Primary Care-Specialty Care Interface for Cardiology in the Medically Underserved: A Cluster-Randomized Controlled Trial

J. Nwando Olayiwola , and colleagues

Background The exchange of information between primary care clinicians and specialists to whom they refer patients is often not optimal. This study tests the efficacy and effectiveness of electronic consultations (eConsults) in reducing wait times and improving access to cardiac care for underserved populations.

What This Study Found Electronic consultations appear to improve access to and timeliness of referrals to cardiac care. eConsults also reduce overall specialty utilization and streamline specialty referrals without an increase in adverse cardiovascular outcomes. Two-thirds or patients referred to a cardiologist by the e-consultation pathway never required a face-to-face visit. Electronic consultations were completed, on average, almost a month sooner than face-to face consultations, even for those deemed urgent by the referring physician. After six months, there were fewer cardiac-related emergency department visits for the intervention group.

Implications

  • These results suggest that a substantial number of consultations can be safely and more efficiently managed through a secure electronic exchange of information without compromising the quality of care and with improved convenience for the patient.

Influence of Clinical Communication on Parents' Antibiotic Expectations for Children With Respiratory Tract Infections

Christie Cabral , and colleagues

Background The use of antibiotics is an important factor in antibiotic resistance, a major risk to health services. This study examines how clinician communication about antibiotics for respiratory tract infection influences parents' understanding and expectations of antibiotic treatment.

What This Study Found Clinician communication and prescribing behavior confirms parents' beliefs that antibiotics are needed to treat more severe illnesses. Clinicians offered minimal explanations of the diagnostic decision and used language that equated a viral diagnosis with less severe illness. This may explain why the public accepts that antibiotics do not treat viruses, but have unchanged antibiotic expectations for particular symptoms or particularly disruptive illnesses.

Implications

  • Communication aimed at reducing antibiotic expectations, the authors suggest, would be more effective if it acknowledges that viral illness can be severe (e.g., in bronchitis or viral pneumonia) and that bacterial infections can be self-limiting.
  • Clearer explanations of the symptoms and signs of a child's illness that indicate when antibiotics are and are not warranted could help reduce misconceptions.

Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels

Jessica Greene , and colleagues

Background Patient activation (the knowledge, confidence, and skills to take care of one?s health and healthcare) is associated with health-related outcomes. This study aims to shed light on clinician behaviors that support greater activation and how these behaviors are associated with better outcomes.

What This Study Found Exemplar physicians use five key strategies to support patient behavior change. They, 1) emphasize patient ownership; 2) partner with patients; 3) identify small steps; 4) schedule frequent follow-up visits to cheer successes, problem solve, or both; and 5) show care and concern for patients. Clinicians whose patients have low activation are far less likely to describe using these approaches.

Implications

  • Given the key role patients play in determining health outcomes, it is critical that primary care physicians support patient self-management and activation. The authors call for more systematic professional and organizational approaches to help clinicians adopt evidence-based strategies to support patients and increase activation levels.

Disclosure of Sexual Orientation and Uptake of HIV Testing and Hepatitis Vaccination for Rural Men Who Have Sex With Men

Nicholas Metheny , and colleagues

Background Primary care clinicians' ability of to make recommendations for routine HIV testing and hepatitis vaccines are shaped by knowledge of their patient's risk behaviors. For men who have sex with men (MSM), this requires disclosure of same-sex sexual behavior or sexual identity. This study analyzes whether disclosing sexual identity is associated with increased HIV testing and hepatitis vaccinations among rural MSM.

What This Study Found For rural MSM, being fully "out" to their clinician and talking openly about their sexuality is a fundamental gateway to receiving appropriate sexual health services. Full disclosure of sexual orientation to their primary care clinician sharply increases the probability that rural men who have sex with men receive recommended HIV testing and hepatitis A and B vaccinations.

Implications

  • This finding, according to the authors, reinforces the need for safe, nonjudgemental spaces for patients to freely discuss their sexual identities with their clinicians.

Achieving Value In Primary Care: The Primary Care Value Model

William Rollow , and colleagues

Background The patient centered medical home model has been the guiding vision for transformation of primary care, however, it has produced inconsistent results with varying interpretations. The authors propose a framework for defining patient-centered value and a model for value-based primary care transformation.

What This Study Found The proposed framework is based on five domains that are important to patients: health, cure, healing, preconditions of health, and experience of care. The proposed primary care value model has three tiers of additive and complementary activities: 1) foundational activities providing organizational infrastructure, 2) direct care activities providing medical and complementary services, and 3) care coordination activities providing coordination and support for direct care activities.

Implications

  • The authors advocate for use of this model when measuring the impact of primary care transformation, recognition, and performance-based payment; for financial support and research; and to support primary care organizations in transformation.

Family Physician-Case Manager Collaboration and Needs of Patients With Dementia and Their Caregivers: A Systematic Mixed Studies Review

Vladimir Khanassov , and colleagues

Background Patients with dementia and their caregivers who already receive professional care still report unmet needs. This analysis of existing research sets out to determine whether case management (the collaboration of family physicians with case managers) responds to the needs of patients with dementia living in the community and their caregivers.

What This Study Found Case management addresses the majority of needs of dementia patients and caregivers. Some very frequent needs, such as early diagnosis, are still overlooked, and other needs, such as education/information, are well targeted.

Implications

  • The authors call for future studies to evaluate the effects of case management on needs that are overlooked, specifically early diagnosis of dementia, legal issues, and financial issues. Integration of social workers into primary care to assist with financial and legal issues may be an avenue for future studies.

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