Kim S. Kimminau

Discussing Weight with Obese Primary Care Patients: Physician and Patient Perceptions

AbstractsObjectiveTo evaluate patient–provider agreement on whether weight and related behaviors were discussed during routine visits.DesignPost-visit survey assessments of patients and providers.ParticipantsObese patients make up the majority of all patients seen in primary care (PC). The patients and physicians were recruited at the time of PC visits.Measurements and Main ResultsPercent patient–physician agreement and patient, provider and practice characteristics associated with agreement. Patients (456) and physicians (30) agreed about whether or not they discussed weight, physical activity (PA), and diet for 61% of office visits. There was disagreement on one of the items (weight, PA, or diet) for 23% of office visits, and for 2 or more of the items for 16% of the visits. Agreement was relatively greater for discussing weight than for discussing diet or physical activity. Physicians reported discussing weight issues more often than did patients. Overall patient–physician agreement was 0.51–0.59 (weighted Kappa statistic). In a multivariate analyses of factors associated with patient–physician agreement, health insurance (odds ratio [OR]=3.67, p value = 0.002), physician description of patient weight status (OR = 2.27, p value = 0.002), patient report of how weight relates to health (OR = 1.70, p value = 0.04), and female patient gender (OR = 1.62, p = value = 0.02) were significantly related to agreement.ConclusionsPatients and providers disagreed about whether or not weight issues were discussed in a large number of primary care encounters in this study. Physicians may be able to improve care for their obese patients by focusing discussions on specific details of diet and physical activity behaviors, and by clarifying that patients perceive weight-related information has been shared.

Improving evidence-based primary care for chronic kidney disease: study protocol for a cluster randomized control trial for translating evidence into practice (TRANSLATE CKD)

BackgroundChronic kidney disease (CKD) and end stage renal disease (ESRD) are steadily increasing in prevalence in the United States. While there is reasonable evidence that specific activities can be implemented by primary care physicians (PCPs) to delay CKD progression and reduce mortality, CKD is under-recognized and undertreated in primary care offices, and PCPs are generally not familiar with treatment guidelines. The current study addresses the question of whether the facilitated TRANSLATE model compared to computer decision support (CDS) alone will lead to improved evidence-based care for CKD in primary care offices.Methods/DesignThis protocol consists of a cluster randomized controlled trial (CRCT) followed by a process and cost analysis. Only practices providing ambulatory primary care as their principal function, located in non-hospital settings, employing at least one primary care physician, with a minimum of 2,000 patients seen in the prior year, are eligible. The intervention will occur at the cluster level and consists of providing CKD-specific CDS versus CKD-specific CDS plus practice facilitation for all elements of the TRANSLATE model. Patient-level data will be collected from each participating practice to examine adherence to guideline-concordant care, progression of CKD and all-cause mortality. Patients are considered to meet stage three CKD criteria if at least two consecutive estimated glomerular filtration rate (eGFR) measurements at least three months apart fall below 60 ml/min. The process evaluation (cluster level) will determine through qualitative methods the fidelity of the facilitated TRANSLATE program and find the challenges and enablers of the implementation process. The cost-effectiveness analysis will compare the benefit of the intervention of CDS alone against the intervention of CDS plus TRANSLATE (practice facilitation) in relationship to overall cost per quality adjusted years of life.DiscussionThis study has three major innovations. First, this study adapts the TRANSLATE method, proven effective in diabetes care, to CKD. Second, we are creating a generalizable CDS specific to the Kidney Disease Outcome Quality Initiative (KDOQI) guidelines for CKD. Additionally, this study will evaluate the effects of CDS versus CDS with facilitation and answer key questions regarding the cost-effectiveness of a facilitated model for improving CKD outcomes. The study is testing virtual facilitation and Academic detailing making the findings generalizable to any area of the country.Trial registrationRegistered as NCT01767883 on clinicaltrials.gov NCT01767883

Sources of Health Information in a Multiethnic, Underserved, Urban Community: Does Ethnicity Matter?

The Latino population is the fastest growing minority in the country, and is expected to reach about 30% of the total U.S. population by 2050. Historically, primary care practitioners are not the preferred source of health information for Latinos living in the United States. Latinos are known to rely more on media, family, and friends to get answers to health-related questions. Choosing the appropriate information source is an important component of health information–seeking behavior; it also represents a major challenge for health communicators trying to deliver information to their target audience. This study explores how ethnicity influences health information source selection among Latinos and White non-Latinos living together in an underserved, multiethnic urban community with poor health status and underlying socioeconomic characteristics. The results suggest that this community manifests a high degree of homogeneity in their usage of health information sources. Nevertheless, there are significant differences between ethnic groups and age groups on perceived usefulness of the health information retrieved from common sources. Our results suggest that health information sources that are interactive, native to the community (e.g., the local pharmacist), and promote active engagement are the most useful in delivering health messages that will be listened to by those living in this underserved, multiethnic urban community.

Understanding the Role of Violence in Incarcerated Women's Cervical Cancer Screening and History

In this exploratory study the authors investigated characteristics, including reported experiences of violence, related to incarcerated womens self-report of cervical cancer screening and cancer history and treatment. During a four month period in 2010, 204 women in Kansas City jails were surveyed. Multiple logistic regression models were used to examine the relations of socio-demographic and community characteristics and history of violence among the women to their cervical cancer screening, diagnosis, and treatment histories. Forty percent of the women in the current sample reported abnormal Pap histories, though only 6% of all Pap smears done in the U.S. are abnormal. Women who reported abuse histories in this study were found to be more likely to report having ever had an abnormal Pap smear (for physical abuse Odds Ratio [OR] = 6.05; CI 2.36, 15.54 and for past year intimate partner violence OR = 2.41; CI 1.09, 5.31). Participants who did not fear neighborhood violence were less likely to report an abnormal Pap history (OR = 0.57; CI 0.34, 0.96) and more likely to visit a family doctor for their Pap screenings (OR = 1.91; CI 1.01, 3.60). Women who perceived greater neighborhood violence had increased odds of reporting that they received Pap screenings in a hospital setting (OR = 1.47; CI 1.08, 2.00). Frequency of Pap screening did not differ in women who did and did not have fear of neighborhood violence. This study highlights the heightened cervical cancer risk experienced by women with criminal justice histories and suggests that violence at several levels has implications for cervical cancer prevention for these women.

Using Health Information Technology to Engage Communities in Health, Education, and Research

The Internet can be used for personal health management as well as to facilitate partnerships and data-sharing in a community setting. Engaging Communities In August 2011, scientists and policy-makers held a conference entitled “Using Information Technology to Improve Community Health: How Health Care Reform Supports Innovation.” At the conference, four “Think Tank” sessions convened, one which was “Health Information Technology (HIT) as a Resource to Improve Community Health and Education.” During this session, a diverse group of 30 individuals discussed ways that HIT could engage communities to improve patient health, education, and research involvement. The August 2011 Clinical and Translational Science Awards conference “Using IT to Improve Community Health: How Health Care Reform Supports Innovation” convened four “Think Tank” sessions. Thirty individuals, representing various perspectives on community engagement, attended the “Health information technology (HIT) as a resource to improve community health and education” session, which focused on using HIT to improve patient health, education, and research involvement. Participants discussed a range of topics using a semistructured format. This article describes themes and lessons that emerged from that session, with a particular focus on using HIT to engage communities to improve health and reduce health disparities in populations.

Inaccuracy of ICD-9 Codes for Chronic Kidney Disease: A Study from Two Practice-based Research Networks (PBRNs)

Background: Inaccurate use of International Classification of Diseases, Ninth Revision (ICD-9), codes obfuscates registries used for research, resulting in unreliable data and inaccurate measurement of outcomes, and it may contribute to mismanagement of patients. Thus it is important to understand the prevalence of ICD-9 code misuse. We chose chronic kidney disease (CKD) as a condition of interest after several patients recruited for a previous study indicated they did not have the disease, despite the presence of the ICD-9 code (585.x) in their electronic medical record (EMR). Methods: Retrospective chart review of patients with the ICD-9 code for CKD stage 3 (585.3; n = 325). Data were collected from EMRs at 3 primary care practices Buffalo, New York (n = 2), and Kansas City, Kansas (n = 1). Results: Across all practices, 47% of patients with the CKD ICD-9 code did not have clinical indicators for the disease, based on Kidney Disease Outcomes Quality Initiative guidelines. Conclusions: The CKD stage 3 ICD-9 code usage did not accurately reflect the prevalence of disease among this population. This has clinical implications because patients may be treated or receive tests for a disease they do not have. This also presents an important issue for research projects that rely on accurate data from EMRs to identify and recruit patients.

Ecologic Correlates of Obesity in Rural Obese Adults

Objective: We examined relationships of individual and environmental factors with obesity and trying to lose weight in rural residents. Methods: The joint contributions of individual and environmental factors on obesity status (obese vs. morbidly obese) and trying to lose weight (yes vs. no) were evaluated using generalized estimating equations. Patients at 29 clinics in rural areas (N = 414, M age 55.0 years (SD = 15.4), 66.3% female) completed anthropometric assessments of weight and height along with survey assessments of individual sociodemographics and trying to lose weight. Rural environments were assessed on aggregated physician access, and sociodemographic context. Results: Most participants (70%, M BMI = 38.3) were obese and 30% morbidly obese. A majority (73%, n = 302) of the sample was trying to lose weight. Compared to obese, morbidly obese participants were more likely to be younger, disproportionately female, not have private insurance, have more comorbid conditions, and rate themselves in worse health in comparison to their obese peers. Compared to not trying to lose weight, trying to lose weight participants were more likely to be younger, disproportionately female, have fewer comorbid conditions, and have attempted to lose weight more times through exercise. Few relationships were seen between environmental variables and obesity or trying to lose weight. Conclusions: There was no consistent pattern of relationships between environment factors and obesity or trying to lose weight was seen. Unique aspects of rural living may not be captured by traditionally available neighborhood measures.

Protocol for the Rural Engagement in Primary Care for Optimizing Weight Reduction (RE-POWER) Trial: Comparing three obesity treatment models in rural primary care.

Obesity disproportionately affects rural residents in the United States, and primary care has the potential to fill a major gap in the provision of weight management services for rural communities. The objective of this cluster-randomized pragmatic trial is to evaluate the comparative effectiveness of three obesity treatment models in rural primary care: the Intensive Behavior Therapy fee-for-service (FFS) model reimbursed by Medicare, a team-based model that recognizes the patient-centered medical home (PCMH) as a preferred delivery approach, and the centralized disease management (DM) model, in which phone-based counseling is provided outside of the primary care practice. We hypothesize that the PCMH and DM treatments will be more effective than FFS in reducing weight at 24 months. Thirty-six practices from the rural Midwestern U.S. are randomized to deliver one of the three interventions to 40 patients (N=1440) age 20 to 75 with a BMI 30-45 kg/m(2). In the FFS arm, primary care providers and their personnel counsel patients to follow evidence-based weight loss guidelines using the Medicare-designated treatment schedule. In the PCMH arm, patients receive a comprehensive weight management intervention delivered locally by practice personnel using a combination of in-person and phone-based group sessions. In the DM arm, the same intervention is delivered remotely by obesity treatment specialists via group conference calls. The primary outcome is weight loss at 24 months. Additional measures include fasting glucose, lipids, quality of life indicators, and implementation process measures. Findings will illuminate effective obesity treatment intervention(s) in rural primary care.

Effect of 2 Clinical Decision Support Strategies on Chronic Kidney Disease Outcomes in Primary Care: A Cluster Randomized Trial

Key Points Question Can clinical decision support plus practice facilitation improve treatment of chronic kidney disease (CKD) in primary care, with the goal of delaying progression of CKD from stages 3 and 4? Findings This cluster randomized clinical trial of 30 primary care practices comprising 6699 patients showed a significant effect in the intervention group compared with the control group in slowing the annualized loss of estimated glomerular filtration rate in patients with stages 3 and 4 CKD. There was significant improvement in hemoglobin A1c over time among patients in the intervention group compared with patients in the control group, with an imbalance between groups resulting from practice dropout posing a significant limitation. Meaning Findings suggest that a multimodal intervention in primary care can slow the progression of stages 3 and 4 CKD.

Patient Factors That Influence How Physicians Discuss Active Surveillance With Low-Risk Prostate Cancer Patients: A Qualitative Study:

For men diagnosed with prostate cancer, making treatment decisions can be overwhelming. Navigating treatment options, along with potential treatment side effects, can be difficult, and patients often rely heavily on the advice of their physicians. This study was aimed at understanding more about the way urologists talk with their patients about one treatment option: active surveillance (AS), a recognized management strategy for men with low-risk prostate cancer that includes close observation and monitoring of the cancer. This study reports, through 22 interviews with urologists, that urologists believe patients are hesitant about AS for a number of reasons, including misperceptions about cancer severity, anxiety, aversion to repeated biopsies that accompany AS, or family member preferences. Because urologists play an influential role in educating patients about treatment options, the discussion around AS can be impacted by barriers that physicians believe matter for their patients. Improving awareness among urologists about what factors impact their patient education about low-risk prostate cancer is important. Identifying tools to improve shared decision making in this area could result in treatment decisions that are increasingly concordant with patients’ values, concerns, and goals.