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Obesity Management In Primary Care: Assessment of Readiness to Change Among 284 Family Practice Patients

Background: Most adults in primary care are overweight or obese; two thirds of patients with weight problems have other obesity-related conditions. The study objective was to explore the feasibility of a primary care obesity intervention based on the transtheoretical model (TM) of behavior change and principles of chronic disease (CD) care. Methods: A prospective study of the initial version of the TM-CD intervention with obese family practice patients (n = 284) yielded cross-sectional data on baseline stage of change for six target behaviors: dietary fat, portion control, vegetable intake, fruit intake, usual physical activity, and planned exercise. The sample consisted of obese patients scheduled for an office visit during times when recruitment and informed consent did not conflict with acute care. Results: Obese patients volunteering for a TM-CD program are in different stages of change for six target behaviors. Preparation was the most frequently reported stage for increased exercise (49%) or activity (34%), decreased dietary fat consumption (44%), and increased portion control (51%). Patients in a particular stage for one behavior were distributed across all five stages for another behavior. Stage of change for five target behaviors was associated with body mass index or waist girth (P < .05) in a manner consistent with stage-of-change theory. Conclusions: Using the transtheoretical model of behavior change will allow physicians to recognize when obese patients are receptive to specific behavioral interventions.

Exercise Stage of Change and Self-Efficacy in Primary Care: Implications for Intervention

Multiple chronic diseases are caused or complicated by a sedentary lifestyle. Thus, an important and challenging application of psychology in clinical settings is changing the behavior of sedentary primary care patients. This study focused on exercise stage of change and self-efficacy in a sample of adult family practice patients recruited while waiting for their scheduled physician appointment. Regarding exercise stage of change, 15% of respondents were in the Precontemplation stage, 26% in the Contemplation stage, 50% in the Preparation stage, 7% in the Action stage, and 13% in the Maintenance stage. Mean self-efficacy scores for exercise were significantly higher among respondents in the Action and Maintenance stages of change. These cross-sectional data are consistent with the hypothesis that movement through the exercise stages of change could be encouraged by clinical interventions that increase exercise self-efficacy. The identification of multiple personal opportunities for increasing exercise self-efficacy may be clinically useful in this context. Recommendations for psychologists in primary care settings in their work with physicians are offered.

Sleep duration, quality, or stability and obesity in an urban family medicine center.

PURPOSE Inadequate sleep has negative metabolic consequences that may contribute to obesity. A priori hypotheses posit relationships between sleep characteristics, carbohydrate and lipid metabolism, appetite, fatigue, and obesity in laboratory, clinical, and population settings. There are few reports from primary care; and none that address sleep duration, quality, and stability. This study examines the relationship between three sleep characteristics-duration, quality, or stability-and obesity in our urban hospital affiliated family medicine center in Akron, Ohio. METHODS A systematic sampling process yielded 225 representative patients who completed the Pittsburgh Sleep Quality Index, the Berlin Apnea Questionnaire, and the Sleep Timing Questionnaire. Demographic, body mass, hypertension, and insurance data were obtained from the electronic medical record. Associations between self-reported sleep characteristics and obesity were examined via contingency tables and regression models. RESULTS Seventy-eight percent (78%) reported poor quality sleep, 59% had elevated Berlin apnea-risk scores, 12% reported restless legs symptoms, and 9% reported a prior diagnosis of sleep apnea; 62% were obese. We found significant (p < 0.05) associations between sleep quality, duration or bedtime stability, and obesity. The association between sleep quality and obesity was negative and linear (69%, 72%, 56%, 43%), while the association between sleep duration and obesity was U-shaped (74%, 53%, 53%, 62%; linear term p = 0.02 and quadratic term p = 0.03). Less stable bedtimes during the week (OR = 2.3, p = 0.008) or on the weekend (OR = 1.8, p = 0.04) were also associated with obesity. The association between sleep quality and obesity was not explained by patient demographics or snoring (ORadj = 2.2; p = 0.008). CONCLUSION This study adds to the sparse literature on the relationship between three self-reported sleep characteristics and obesity in urban primary care settings which typically differ from both general population and specialty outpatient settings.

Using the QIDS-SR16 to Identify Major Depressive Disorder in Primary Care Medical Patients

Major depressive disorder (MDD) is a serious and prevalent mental health issue. As the majority of MDD cases are identified and treated by ones primary care physician, it is imperative that care providers utilize accurate and efficient methods for diagnosing MDD in primary care settings. The present study is the first to investigate the accuracy of the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR(16)) as a screen for MDD. A heterogeneous sample of 155 primary care patients completed the QIDS-SR(16) prior to attending a primary care appointment. Participants were then assessed for psychopathology using the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID) by clinicians who were blind to QIDS-SR(16) scores. Scores on the QIDS-SR(16) were compared to clinician-assessed current and lifetime diagnoses derived from the SCID, which represented the gold-standard criterion measure. Receiver operator characteristic analysis was utilized to determine the optimal QIDS-SR(16) cut score to correctly classify participants based on their MDD status as assessed by the SCID. The test revealed a robust area under the curve (.82, p<0.00001) and suggested that a cut score of 13 or 14 provided the best balance of sensitivity (76.5%) and specificity (81.8%) in this primary care sample. Over 80% of participants were correctly classified. Separate analyses by race were conducted to address the possibility that different cut scores may be more accurate for African American and Caucasians. Findings from the present study provide support for the use of the QIDS-SR(16) as a screening measure for identifying primary care patients who will meet diagnostic criteria for MDD based on clinician assessment.

The better weight-better sleep study: a pilot intervention in primary care.

OBJECTIVE To explore the feasibility of integrating sleep management interventions with dietary and exercise interventions for obesity in a 12-week randomized trial. METHODS We randomized 49 overweight or obese adult patients either to a better weight (BW) cognitive behavioral intervention, or to a combination of the BW intervention and a better sleep intervention, better weight-better sleep (BWBS). RESULTS The BWBS group lost weight faster (P=.04), and coping self-efficacy accelerated (P=.01). CONCLUSIONS These preliminary results merit replication in a larger primary care-based trial with a longer continuous intervention and follow-up period.

Admission Data Predict High Hospital Readmission Risk.

Purpose: The purpose of this study was to identify data available at the time of hospital admission that predict readmission risk. Methods: We performed a retrospective multiple regression analysis of 958 adult, nonpregnant patients admitted to the Family Medicine Service between June 2012 and October 2013. Data were abstracted from hospital administrative sources and electronic medical records. The outcome was 30-day hospital readmission. Candidate readmission predictors included polypharmacy (≥6 medicines), Charlson comorbidity index, age, sex, insurance status, emergency department use, smoking, nursing report of cognitive issues, patient report of social support or financial issues, and a history of heart failure, pneumonia, or chronic obstructive pulmonary disease. Results: Patients at the Family Medicine Service had a 14% readmission risk. Bivariate analysis showed that high Charlson scores (≥5), polypharmacy, heart failure, pneumonia, or chronic obstructive pulmonary disease each increased readmission risk (P < .05). A logistic model showed an estimated odds ratio for readmission for high Charlson scores of 1.7 (95% confidence interval, 1.1–2.6) and of 2.1 for polypharmacy (95% confidence interval, 1.3–3.7). The model yielded a readmission risk estimate of 6% if neither a high Charlson score nor polypharmacy was present, 9% if only the Charlson score was high, 12% if only polypharmacy was present, and 19% if both were present. The receiver operating characteristics curve for the 2-factor model yielded an estimated area under the curve of 85%. Cross-validation supported this result. Conclusions: Polypharmacy and higher Charlson score at admission predict readmission risk as well as or better than published risk prediction models. The model could help to conserve limited resources and to target interventions for reducing readmission among the highest-risk patients.

The relationship among the transtheoretical model of behavioral change, psychological distress, and diet attitudes in obesity: Implications for primary care intervention

Obesity is prevalent but undertreated in primary care. Family practice volunteer outpatients (N=454) were administered the Stage of Change for Weight (URICA), the Brief Symptom Inventory (BSI), and the Diet Readiness Test (DRT) to assess the relationship between these variables and obesity. The body mass index (BMI) was used to classify obesity revealing 197 patients with elevated BMIs. There was no significant difference between the obese and the nonobese on any of the psychological measures. The obese reported significantly more difficulty setting diet goals and less control over their eating, ate more to emotional situations, and exercised less than the nonobese. The obese sample (46.7%) reported being in the Action stage of change for weight management. Implications for intervention in primary care include targeting attitudes (DRT) and dispelling physician attitudes that obese individuals have increased levels of psychological distress. Addressing Stage of Change for weight management can facilitate tailoring the appropriate intervention when used in concert with the DRT variables.

An Opt-Out Influenza Vaccination Policy Improves Immunization Rates in Primary Care

Purpose/Objective. During the 2007–08 influenza season 36% of outpatients seen at our urban family medicine center received an influenza immunization. We explored the expected increase in vaccinations from an opt-out policy using standing orders in a lower-income population.Methods. A comparison of vaccination rates during the periods 10/1/2007 to 3/31/2008 (P1) versus 10/1/2008 to 3/31/2009 (P2) with adjustments for cohort non-independence.Results. The overall P2 vaccination rate increased to 49% [p<.000001]. P2 rates were significantly higher for those with diabetes, both genders, African American and European American patients from 3 to 64 years old, and in all insurance groups. The vaccination rates for patients with Medicaid insurance (37% and 54%) were higher than the rates for patients with commercial insurance (31% and 43%).Conclusions. The opt-out policy is associated with a moderate (1.4 fold) increase in the vaccination rate. Primary care resource constraints may limit further improvement.

Functional and Attitudinal Outcomes of Teaching Functional Assessment to Medical Students.

Teaching geriatric principles to medical students is important because of the increasing geriatric population. Family physicians are in a strategic position to provide this teaching because they provide much of the care for the elderly. The challenge in developing a geriatric curriculum is to determine the content, implement it efficiently, and evaluate its impact. We developed a geriatric assessment experience for third-year medical students. The students were introduced to a geriatric assessment tool and asked to identify a patient, complete the assessment, and record key elements of functional assessment. Student attitudes were measured before and after completing the assessment. The students rated their knowledge, comfort, and experience with a comprehensive geriatric assessment. Students listed approximately seven problems and four recommendations per patient. On average, students identified one functional problem for each patient. There were significant increases in knowledge, comfort, and experienc...

A method for obtaining an unbiased sample of family medicine patients for research purposes.

Introduction: Obtaining a representative patient sample for research purposes can be challenging. Classic probability sampling can be trusted, but these approaches are not always feasible; yet alternatives may introduce bias. We summarize relevant literature, the need for new approaches, and illustrate a practical hybrid approach that could consistently produce representative patient samples. Methods: Valid approaches shift sampling decisions from fallible interviewers to less fallible reproducible processes. In lieu of the interviewers inclination to select particular patients, we used the day of the week, the appointment time, and the sequence of the patients last name in the alphabet to select a sample for a consent process and a survey. Illustrative Use: Characteristics of the study sample (n = 225) were compared with the characteristics of the population (N = 1964) that had an office visit during the recruiting period. The data suggested that the study sample was highly representative of the population in this illustrative case. Discussion: A hybrid sampling approach, in the context of a brief consent process, and a nonthreatening interview produced a representative study sample, but formal evaluation via simulation is needed to validate the hybrid approach. Convenience samples of consecutive patients should be avoided to minimize bias.