Helen E. McIlvain

Delivery of Clinical Preventive Services in Family Medicine Offices

BACKGROUND This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts. METHODS We used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offices from 1997 to 1999. Medical records, observation of outpatient encounters, and patient exit cards were used to calculate practice-level rates of delivery of clinical preventive services. Field notes from direct observation of clinical encounters and prolonged observation of the practice and transcripts from in-depth interviews of practice staff and physicians were systematically examined to identify approaches to delivering clinical preventive services recommended by the US Preventive Services Task Force. RESULTS Practices developed individualized approaches for delivering clinical preventive services, with no one approach being successful across practices. Clinicians acknowledged a 3-fold mission of providing acute care, managing chronic problems, and prevention, but only some made prevention a priority. The clinical encounter was a central focus for preventive service delivery in all practices. Preventive services delivery rates often appeared to be influenced by competing demands within the clinical encounter (including between different preventive services), having a physician champion who prioritized prevention, and economic concerns. CONCLUSIONS Practice quality improvement efforts that assume there is an optimal approach for delivering clinical preventive services fail to account for practices’ propensity to optimize care processes to meet local contexts. Interventions to enhance clinical preventive service delivery should be tailored to meet the local needs of practices and their patient populations.

Using Metaphor as a Qualitative Analytic Approach to Understand Complexity in Primary Care Research

Metaphors offer exciting opportunities to identify and explore tacit knowledge and behavior that are embedded in complex organizations and shape health care practices. In this article, the authors explore the theoretical rationale, background, and advantages of using metaphor as an analytic strategy in qualitative health research. They used an analysis of 18practices in a comparative case study designed to explore office practice strategies for delivering cancer prevention services for illustrations. During the individual and comparative stages of the analysis process, researchers heeded the metaphors that they used in their descriptive language of practices. The authors explore examples showing how metaphors clarify unwritten assumptions, values, and motivators that shape variations in practice behavior.

Feasibility of smoking cessation counseling by phone with alcohol treatment center graduates

Several studies have tested the effectiveness of telephone counseling as a smoking cessation intervention, but few have addressed its application with the special population of smokers who are also problem drinkers or recovering alcoholics. Two hundred and eighty-eight male and female subjects were recruited from six residential alcohol treatment programs in Nebraska, Iowa, and Kansas to receive three postreatment telephone calls based on the stages of change model. Most subjects (71%) participated in at least one telephone counseling session, but only 38% participated in all three. Those who completed of session were significantly (p < .01) more likely to have advanced one stage of change in their readiness to quit smoking and to report having quit smoking for at least 24 hours since leaving treatment (p < .01). Stage-based telephone counseling appears to be a feasible approach to addressing smoking cessation among recovering alcoholics, with a modest positive effect on subsequent tobacco use.

A process evaluation model for patient education programs for pregnant smokers

OBJECTIVE To describe and apply a process evaluation model (PEM) for patient education programs for pregnant smokers. METHODS The preparation of a process evaluation plan required each program to define its essential “new” patient assessment and intervention procedures for each episode (visit) of patient–staff contact. Following specification of these core implementation procedures (p) by each patient education program, the PEM, developed by the Smoke-Free Families (SFF) National Program Office, was applied. The PEM consists of five steps: (1) definition of the eligible patient sample (a); (2) documentation of patient exposure to each procedure (b); (3) computation of procedure exposure rate (b/a = c); (4) specification of a practice performance standard for each procedure (d); (5) computation of an implementation index (c/d = e) for each procedure. The aggregate of all indexes (e) divided by the number of procedures (Pn) produced a program implementation index (PII = Σe/Pn). PARTICIPANTS AND SETTINGS Data from four SFF studies that represent different settings were used to illustrate the application of the PEM. RESULTS All four projects encountered moderate to significant difficulty in program implementation. As the number and complexity of procedures increased, the implementation index decreased. From initial procedures that included patient recruitment, delivery of the intervention components, and conducting patient follow ups, a variety of problems were encountered and lessons learned. CONCLUSION This process evaluation provided specific insight about the difficulty of routine delivery of any new methods into diverse maternity care setting. The importance of pilot testing all procedures is emphasised. The application of the PEM to monitor program progress is recommended and revisions to improve program delivery are suggested.

TOBACCO CESSATION WITH PATIENTS RECOVERING FROM ALCOHOL AND OTHER SUBSTANCE ABUSE

This article focuses on the problem of tobacco cessation in the patient recovering from alcohol or other substance abuse. The authors review the epidemiology of the problem, specific health risks to this population from continued tobacco use, and recent research findings that address previous treatment concerns. Recommendations for counseling by physicians are made. These include an algorithm for determining the patients stage of readiness for making a quit attempt, specific counseling tasks based on the patients stage, and motivational counseling strategies aimed at increasing the patients motivation to quit.

Interactive software: an educational/behavioural approach to smoking cessation for pregnant women and their families

Smoking cessation programs that have been used during pregnancy include brochures, physician advice, and counselling. Standardised self help brochures alone have minimal impact1; tailored messages are more effective.2 Face to face counselling requires training and is time consuming in a busy clinic. Multimedia (non-text based) approaches can reach populations with low literacy levels. Interactive digital media also allows users to learn by making choices and then noting the consequences of their actions. Health messages can be tailored to the user in real time. We designed a digital, interactive smoking cessation intervention tailored for pregnant women and tested it in public health clinics. The study population consisted of pregnant smokers enrolled in the Douglas County (Omaha), Nebraska Women, Infants and Children (WIC) program. The mission of the WIC program is to decrease the number of low birth weight babies born to low income or otherwise at risk women. At the time the study was initiated, the most recent 12 month data available from the Centers for Disease Control (CDC) Pregnancy Nutrition Surveillance program was from 1992. These data indicated that 31.9% of Douglas County WIC participants smoked during pregnancy. Pregnant women who were current smokers (defined as a client who “self reported smoking at least one puff of a cigarette in the last seven days”) were eligible for study participation. Informed consent was obtained following guidelines of the Creighton University institutional review board. Women received vouchers from WIC on a monthly basis and this provided an opportunity for us to collect data. Incentives (

Association of number of follow-up providers with outcomes in survivors of hematologic malignancies

10 vouchers for merchandise at a local store—marked “not for alcohol or tobacco”) were given to participants at the completion of each study …

Effect of smoking cessation counseling on recovery from alcoholism: findings from a randomized community intervention trial

Studies examining follow-up care among cancer survivors have increased in number, and are mostly focused on who best provides care. It is not known whether having single or multiple physicians as follow-up providers has outcome implications. We prospectively studied the association between number of follow-up providers among survivors of hematologic malignancies and serious medical utilization (defined as emergency room visits or hospitalizations) within a 6-month period. Patients completing treatment (n = 314) were included. Patients seeing multiple follow-up providers were more likely to be younger, to reside farther away from the university hospital, to have prescription drug insurance, to have received prior cancer treatment, to have multiple myeloma, and to have undergone hematopoietic cell transplant as a part of cancer treatment. Multivariate analysis showed that the number of follow-up providers was not associated with serious medical utilization (odds ratio 1.29, 95% confidence interval 0.68–2.48, p = 0.44) after adjusting for patient factors. Our study showed that among survivors of hematologic malignancies, outcomes were not different for survivors who were seen by single or multiple follow-up providers.